|
TDAP Vaccine >7 IM 90715 VFC
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
5076614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$165.11 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.78
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$165.11
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$101.62
|
|
|
TD Vaccine No Prsrv >/= 7 IM 90714
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3455569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.91 |
| Max. Negotiated Rate |
$162.12 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Aetna Managed Medicare |
$30.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.91
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.68
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: NAPHCARE Commercial |
$66.14
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$71.66
|
| Rate for Payer: Quartz Medicare Advantage |
$66.14
|
| Rate for Payer: The Alliance Commercial |
$162.12
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$48.95
|
|
|
TD Vaccine No Prsrv >/= 7 IM 90714
|
Professional
|
Both
|
$106.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3455569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.58 |
| Max. Negotiated Rate |
$104.73 |
| Rate for Payer: Aetna Commercial |
$104.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Aetna Managed Medicare |
$40.53
|
| Rate for Payer: Anthem Medicare Advantage |
$40.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$40.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$40.53
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$104.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.58
|
| Rate for Payer: Health EOS Commercial |
$100.32
|
| Rate for Payer: HFN Commercial |
$104.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$40.53
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: NAPHCARE Commercial |
$60.79
|
| Rate for Payer: Preferred Network Access Commercial |
$104.73
|
| Rate for Payer: Quartz Beloit One Network |
$48.51
|
| Rate for Payer: Quartz Commercial |
$62.84
|
| Rate for Payer: Quartz Medicare Advantage |
$40.53
|
| Rate for Payer: The Alliance Commercial |
$101.32
|
| Rate for Payer: United Healthcare Medicaid |
$43.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.53
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$48.95
|
|
|
TD Vaccine No Prsrv >/= 7 IM 90714
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3455569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.02 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$66.14
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
|
TEETH EXTRACTION, BABY (1-6)
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960406
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TEETH EXTRACTION, BABY (1-6)
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960406
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TEETH EXTRACTIONS, FULL MOUTH
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960408
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TEETH EXTRACTIONS, FULL MOUTH
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960408
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TEETH EXTRACTIONS, MULTIPLE (1-6)
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960409
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TEETH EXTRACTIONS, MULTIPLE (1-6)
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960409
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TEETH EXTRACTION, WISDOM TEETH
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TEETH EXTRACTION, WISDOM TEETH
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TEETH FILLINGS
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960407
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TEETH FILLINGS
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960407
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
Teichoic Acid Antibody w/ Reflex
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
983419
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$133.52 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
Teichoic Acid Antibody w/ Reflex
|
Professional
|
Both
|
$262.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
983419
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.46 |
| Max. Negotiated Rate |
$258.86 |
| Rate for Payer: Aetna Commercial |
$258.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Aetna Managed Medicare |
$12.46
|
| Rate for Payer: Anthem Medicare Advantage |
$12.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.46
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$258.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.46
|
| Rate for Payer: Health EOS Commercial |
$247.96
|
| Rate for Payer: HFN Commercial |
$258.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: NAPHCARE Commercial |
$18.69
|
| Rate for Payer: Preferred Network Access Commercial |
$258.86
|
| Rate for Payer: Quartz Beloit One Network |
$119.89
|
| Rate for Payer: Quartz Commercial |
$155.31
|
| Rate for Payer: Quartz Medicare Advantage |
$12.46
|
| Rate for Payer: The Alliance Commercial |
$49.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.46
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$54.82
|
|
|
Teichoic Acid Antibody w/ Reflex
|
Facility
|
OP
|
$262.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
983419
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.46 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Aetna Managed Medicare |
$12.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.68
|
| Rate for Payer: Anthem Medicare Advantage |
$12.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.46
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.46
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: NAPHCARE Commercial |
$18.69
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$177.11
|
| Rate for Payer: Quartz Medicare Advantage |
$12.46
|
| Rate for Payer: The Alliance Commercial |
$49.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.46
|
| Rate for Payer: United Healthcare PPO |
$204.36
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: Wellcare Medicare |
$12.46
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
Telemetry (All units EXCEPT Intermediate) - Devices and Equipment
|
Facility
|
IP
|
$591.00
|
|
| Hospital Charge Code |
3716170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$301.17 |
| Max. Negotiated Rate |
$565.47 |
| Rate for Payer: Aetna Commercial |
$553.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.76
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$565.47
|
| Rate for Payer: Health EOS Commercial |
$547.03
|
| Rate for Payer: HFN Commercial |
$565.47
|
| Rate for Payer: Multiplan Commercial |
$491.71
|
| Rate for Payer: Preferred Network Access Commercial |
$565.47
|
| Rate for Payer: Quartz Beloit One Network |
$301.17
|
| Rate for Payer: Quartz Commercial |
$368.78
|
| Rate for Payer: WEA Trust Commercial |
$338.05
|
| Rate for Payer: WPS Commercial |
$455.25
|
|
|
Telemetry (All units EXCEPT Intermediate) - Devices and Equipment
|
Facility
|
OP
|
$591.00
|
|
| Hospital Charge Code |
3716170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$172.10 |
| Max. Negotiated Rate |
$565.47 |
| Rate for Payer: Aetna Commercial |
$553.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.59
|
| Rate for Payer: Aetna Managed Medicare |
$172.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$399.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$295.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.76
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$565.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$343.96
|
| Rate for Payer: Health EOS Commercial |
$547.03
|
| Rate for Payer: HFN Commercial |
$565.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$460.98
|
| Rate for Payer: Multiplan Commercial |
$491.71
|
| Rate for Payer: NAPHCARE Commercial |
$368.78
|
| Rate for Payer: Preferred Network Access Commercial |
$565.47
|
| Rate for Payer: Quartz Beloit One Network |
$301.17
|
| Rate for Payer: Quartz Commercial |
$399.52
|
| Rate for Payer: Quartz Medicare Advantage |
$368.78
|
| Rate for Payer: The Alliance Commercial |
$307.32
|
| Rate for Payer: WEA Trust Commercial |
$338.05
|
| Rate for Payer: WPS Commercial |
$455.25
|
|
|
TELESCOPIC MOTOR STRUT LONG 239-351MM 4934-0-360
|
Facility
|
OP
|
$10,071.06
|
|
| Hospital Charge Code |
6240151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,932.69 |
| Max. Negotiated Rate |
$9,635.99 |
| Rate for Payer: Aetna Commercial |
$9,426.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,007.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,932.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,808.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,236.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,027.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,551.17
|
| Rate for Payer: Cash Price |
$3,021.32
|
| Rate for Payer: Cigna Commercial |
$9,635.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,861.36
|
| Rate for Payer: Health EOS Commercial |
$9,321.77
|
| Rate for Payer: HFN Commercial |
$9,635.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,855.43
|
| Rate for Payer: Multiplan Commercial |
$8,379.12
|
| Rate for Payer: NAPHCARE Commercial |
$6,284.34
|
| Rate for Payer: Preferred Network Access Commercial |
$9,635.99
|
| Rate for Payer: Quartz Beloit One Network |
$5,132.21
|
| Rate for Payer: Quartz Commercial |
$6,808.04
|
| Rate for Payer: Quartz Medicare Advantage |
$6,284.34
|
| Rate for Payer: The Alliance Commercial |
$5,236.95
|
| Rate for Payer: WEA Trust Commercial |
$5,760.65
|
| Rate for Payer: WPS Commercial |
$7,757.74
|
|
|
TELESCOPIC MOTOR STRUT LONG 239-351MM 4934-0-360
|
Facility
|
IP
|
$10,071.06
|
|
| Hospital Charge Code |
6240151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,132.21 |
| Max. Negotiated Rate |
$9,635.99 |
| Rate for Payer: Aetna Commercial |
$9,426.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,007.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,551.17
|
| Rate for Payer: Cash Price |
$3,021.32
|
| Rate for Payer: Cigna Commercial |
$9,635.99
|
| Rate for Payer: Health EOS Commercial |
$9,321.77
|
| Rate for Payer: HFN Commercial |
$9,635.99
|
| Rate for Payer: Multiplan Commercial |
$8,379.12
|
| Rate for Payer: Preferred Network Access Commercial |
$9,635.99
|
| Rate for Payer: Quartz Beloit One Network |
$5,132.21
|
| Rate for Payer: Quartz Commercial |
$6,284.34
|
| Rate for Payer: WEA Trust Commercial |
$5,760.65
|
| Rate for Payer: WPS Commercial |
$7,757.74
|
|
|
TELESCOPIC MOTOR STRUT MEDIUM 187-247MM 4934-0-270
|
Facility
|
OP
|
$10,071.76
|
|
| Hospital Charge Code |
6240150
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,932.90 |
| Max. Negotiated Rate |
$9,636.66 |
| Rate for Payer: Aetna Commercial |
$9,427.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,008.18
|
| Rate for Payer: Aetna Managed Medicare |
$2,932.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,808.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,237.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,027.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,551.55
|
| Rate for Payer: Cash Price |
$3,021.53
|
| Rate for Payer: Cigna Commercial |
$9,636.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,861.76
|
| Rate for Payer: Health EOS Commercial |
$9,322.42
|
| Rate for Payer: HFN Commercial |
$9,636.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,855.97
|
| Rate for Payer: Multiplan Commercial |
$8,379.70
|
| Rate for Payer: NAPHCARE Commercial |
$6,284.78
|
| Rate for Payer: Preferred Network Access Commercial |
$9,636.66
|
| Rate for Payer: Quartz Beloit One Network |
$5,132.57
|
| Rate for Payer: Quartz Commercial |
$6,808.51
|
| Rate for Payer: Quartz Medicare Advantage |
$6,284.78
|
| Rate for Payer: The Alliance Commercial |
$5,237.32
|
| Rate for Payer: WEA Trust Commercial |
$5,761.05
|
| Rate for Payer: WPS Commercial |
$7,758.28
|
|
|
TELESCOPIC MOTOR STRUT MEDIUM 187-247MM 4934-0-270
|
Facility
|
IP
|
$10,071.76
|
|
| Hospital Charge Code |
6240150
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,132.57 |
| Max. Negotiated Rate |
$9,636.66 |
| Rate for Payer: Aetna Commercial |
$9,427.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,008.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,551.55
|
| Rate for Payer: Cash Price |
$3,021.53
|
| Rate for Payer: Cigna Commercial |
$9,636.66
|
| Rate for Payer: Health EOS Commercial |
$9,322.42
|
| Rate for Payer: HFN Commercial |
$9,636.66
|
| Rate for Payer: Multiplan Commercial |
$8,379.70
|
| Rate for Payer: Preferred Network Access Commercial |
$9,636.66
|
| Rate for Payer: Quartz Beloit One Network |
$5,132.57
|
| Rate for Payer: Quartz Commercial |
$6,284.78
|
| Rate for Payer: WEA Trust Commercial |
$5,761.05
|
| Rate for Payer: WPS Commercial |
$7,758.28
|
|
|
Teletherapy Isodose Plan-Complex 7730726
|
Professional
|
Both
|
$2,185.00
|
|
|
Service Code
|
CPT 77307 26
|
| Hospital Charge Code |
5258631
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$152.84 |
| Max. Negotiated Rate |
$2,158.78 |
| Rate for Payer: Aetna Commercial |
$2,158.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,954.26
|
| Rate for Payer: Aetna Managed Medicare |
$152.84
|
| Rate for Payer: Anthem Medicare Advantage |
$152.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$152.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$152.84
|
| Rate for Payer: Cash Price |
$655.50
|
| Rate for Payer: Cash Price |
$655.50
|
| Rate for Payer: Cash Price |
$655.50
|
| Rate for Payer: Cigna Commercial |
$2,158.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,136.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.84
|
| Rate for Payer: Health EOS Commercial |
$2,067.88
|
| Rate for Payer: HFN Commercial |
$2,158.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$544.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$544.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$152.84
|
| Rate for Payer: Multiplan Commercial |
$1,817.92
|
| Rate for Payer: NAPHCARE Commercial |
$229.26
|
| Rate for Payer: Preferred Network Access Commercial |
$2,158.78
|
| Rate for Payer: Quartz Beloit One Network |
$999.86
|
| Rate for Payer: Quartz Commercial |
$1,295.27
|
| Rate for Payer: Quartz Medicare Advantage |
$152.84
|
| Rate for Payer: The Alliance Commercial |
$580.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.84
|
| Rate for Payer: WEA Trust Commercial |
$1,249.82
|
| Rate for Payer: WPS Commercial |
$764.19
|
|
|
Teletherapy Isodose Plan-Simple 7730626
|
Professional
|
Both
|
$861.00
|
|
|
Service Code
|
CPT 77306 26
|
| Hospital Charge Code |
5258630
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.18 |
| Max. Negotiated Rate |
$850.67 |
| Rate for Payer: Aetna Commercial |
$850.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$770.08
|
| Rate for Payer: Aetna Managed Medicare |
$74.18
|
| Rate for Payer: Anthem Medicare Advantage |
$74.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$74.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$74.18
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$850.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$447.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.18
|
| Rate for Payer: Health EOS Commercial |
$814.85
|
| Rate for Payer: HFN Commercial |
$850.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$262.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$262.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$74.18
|
| Rate for Payer: Multiplan Commercial |
$716.35
|
| Rate for Payer: NAPHCARE Commercial |
$111.27
|
| Rate for Payer: Preferred Network Access Commercial |
$850.67
|
| Rate for Payer: Quartz Beloit One Network |
$393.99
|
| Rate for Payer: Quartz Commercial |
$510.40
|
| Rate for Payer: Quartz Medicare Advantage |
$74.18
|
| Rate for Payer: The Alliance Commercial |
$281.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.18
|
| Rate for Payer: WEA Trust Commercial |
$492.49
|
| Rate for Payer: WPS Commercial |
$370.92
|
|
