|
TCM < 14 days 99495RVU
|
Professional
|
Both
|
$314.00
|
|
|
Service Code
|
CPT 99495
|
| Hospital Charge Code |
4512594
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$138.16 |
| Max. Negotiated Rate |
$489.01 |
| Rate for Payer: Aetna Commercial |
$298.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.04
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$298.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$157.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$188.40
|
| Rate for Payer: Health EOS Commercial |
$285.74
|
| Rate for Payer: HFN Commercial |
$298.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$489.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$489.01
|
| Rate for Payer: Multiplan Commercial |
$251.20
|
| Rate for Payer: Preferred Network Access Commercial |
$298.30
|
| Rate for Payer: Quartz Beloit One Network |
$138.16
|
| Rate for Payer: Quartz Commercial |
$178.98
|
| Rate for Payer: The Alliance Commercial |
$157.00
|
| Rate for Payer: WEA Trust Commercial |
$172.70
|
| Rate for Payer: WPS Commercial |
$232.58
|
|
|
TCM < 7 Days 99496
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
CPT 99496
|
| Hospital Charge Code |
3096918
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$160.16 |
| Max. Negotiated Rate |
$665.51 |
| Rate for Payer: Aetna Commercial |
$345.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$345.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$182.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.40
|
| Rate for Payer: Health EOS Commercial |
$331.24
|
| Rate for Payer: HFN Commercial |
$345.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$665.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$665.51
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$345.80
|
| Rate for Payer: Quartz Beloit One Network |
$160.16
|
| Rate for Payer: Quartz Commercial |
$207.48
|
| Rate for Payer: The Alliance Commercial |
$182.00
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
TCM < 7 Days 99496RVU
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
CPT 99496
|
| Hospital Charge Code |
4512595
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$160.16 |
| Max. Negotiated Rate |
$665.51 |
| Rate for Payer: Aetna Commercial |
$345.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$345.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$182.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.40
|
| Rate for Payer: Health EOS Commercial |
$331.24
|
| Rate for Payer: HFN Commercial |
$345.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$665.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$665.51
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$345.80
|
| Rate for Payer: Quartz Beloit One Network |
$160.16
|
| Rate for Payer: Quartz Commercial |
$207.48
|
| Rate for Payer: The Alliance Commercial |
$182.00
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
TCRB Result
|
Facility
|
IP
|
$694.00
|
|
|
Service Code
|
CPT 81340
|
| Hospital Charge Code |
4498644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$340.06 |
| Max. Negotiated Rate |
$638.48 |
| Rate for Payer: Aetna Commercial |
$624.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.82
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$638.48
|
| Rate for Payer: Health EOS Commercial |
$617.66
|
| Rate for Payer: HFN Commercial |
$638.48
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: NAPHCARE Commercial |
$416.40
|
| Rate for Payer: Preferred Network Access Commercial |
$638.48
|
| Rate for Payer: Quartz Beloit One Network |
$340.06
|
| Rate for Payer: Quartz Commercial |
$416.40
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TCRB Result
|
Professional
|
Both
|
$694.00
|
|
|
Service Code
|
CPT 81340
|
| Hospital Charge Code |
4498644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$305.36 |
| Max. Negotiated Rate |
$737.49 |
| Rate for Payer: Aetna Commercial |
$659.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$659.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$347.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$416.40
|
| Rate for Payer: Health EOS Commercial |
$631.54
|
| Rate for Payer: HFN Commercial |
$659.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$737.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$737.49
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: Preferred Network Access Commercial |
$659.30
|
| Rate for Payer: Quartz Beloit One Network |
$305.36
|
| Rate for Payer: Quartz Commercial |
$395.58
|
| Rate for Payer: The Alliance Commercial |
$347.00
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TCRB Result
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
CPT 81340
|
| Hospital Charge Code |
4498644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$208.92 |
| Max. Negotiated Rate |
$835.68 |
| Rate for Payer: Aetna Commercial |
$624.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Aetna Managed Medicare |
$208.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$783.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$365.61
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$346.81
|
| Rate for Payer: Anthem Medicaid |
$215.88
|
| Rate for Payer: Anthem Medicare Advantage |
$208.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$208.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$208.92
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$638.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$208.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$388.36
|
| Rate for Payer: Dean Health Medicaid |
$215.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$208.92
|
| Rate for Payer: Health EOS Commercial |
$617.66
|
| Rate for Payer: HFN Commercial |
$638.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$777.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$208.92
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$215.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$208.92
|
| Rate for Payer: Managed Health Services Medicaid |
$224.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$208.92
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$208.92
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: NAPHCARE Commercial |
$313.38
|
| Rate for Payer: Preferred Network Access Commercial |
$638.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$215.88
|
| Rate for Payer: Quartz Beloit One Network |
$340.06
|
| Rate for Payer: Quartz Commercial |
$451.10
|
| Rate for Payer: Quartz Medicare Advantage |
$208.92
|
| Rate for Payer: The Alliance Commercial |
$835.68
|
| Rate for Payer: United Healthcare Medicaid |
$215.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$208.92
|
| Rate for Payer: United Healthcare PPO |
$520.50
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: Wellcare Medicare |
$208.92
|
| Rate for Payer: WMAP Medicaid |
$215.88
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TCRG Result
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
CPT 81342
|
| Hospital Charge Code |
4498643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$201.50 |
| Max. Negotiated Rate |
$806.00 |
| Rate for Payer: Aetna Commercial |
$624.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Aetna Managed Medicare |
$201.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$755.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$352.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$334.49
|
| Rate for Payer: Anthem Medicaid |
$208.21
|
| Rate for Payer: Anthem Medicare Advantage |
$201.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$201.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$201.50
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$638.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$201.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$388.36
|
| Rate for Payer: Dean Health Medicaid |
$208.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$201.50
|
| Rate for Payer: Health EOS Commercial |
$617.66
|
| Rate for Payer: HFN Commercial |
$638.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$749.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$201.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$208.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$201.50
|
| Rate for Payer: Managed Health Services Medicaid |
$216.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$201.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$201.50
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: NAPHCARE Commercial |
$302.25
|
| Rate for Payer: Preferred Network Access Commercial |
$638.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$208.21
|
| Rate for Payer: Quartz Beloit One Network |
$340.06
|
| Rate for Payer: Quartz Commercial |
$451.10
|
| Rate for Payer: Quartz Medicare Advantage |
$201.50
|
| Rate for Payer: The Alliance Commercial |
$806.00
|
| Rate for Payer: United Healthcare Medicaid |
$208.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$201.50
|
| Rate for Payer: United Healthcare PPO |
$520.50
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: Wellcare Medicare |
$201.50
|
| Rate for Payer: WMAP Medicaid |
$208.21
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TCRG Result
|
Professional
|
Both
|
$694.00
|
|
|
Service Code
|
CPT 81342
|
| Hospital Charge Code |
4498643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$305.36 |
| Max. Negotiated Rate |
$711.30 |
| Rate for Payer: Aetna Commercial |
$659.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$659.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$347.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$416.40
|
| Rate for Payer: Health EOS Commercial |
$631.54
|
| Rate for Payer: HFN Commercial |
$659.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$711.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$711.30
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: Preferred Network Access Commercial |
$659.30
|
| Rate for Payer: Quartz Beloit One Network |
$305.36
|
| Rate for Payer: Quartz Commercial |
$395.58
|
| Rate for Payer: The Alliance Commercial |
$347.00
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TCRG Result
|
Facility
|
IP
|
$694.00
|
|
|
Service Code
|
CPT 81342
|
| Hospital Charge Code |
4498643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$340.06 |
| Max. Negotiated Rate |
$638.48 |
| Rate for Payer: Aetna Commercial |
$624.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.82
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$638.48
|
| Rate for Payer: Health EOS Commercial |
$617.66
|
| Rate for Payer: HFN Commercial |
$638.48
|
| Rate for Payer: Multiplan Commercial |
$555.20
|
| Rate for Payer: NAPHCARE Commercial |
$416.40
|
| Rate for Payer: Preferred Network Access Commercial |
$638.48
|
| Rate for Payer: Quartz Beloit One Network |
$340.06
|
| Rate for Payer: Quartz Commercial |
$416.40
|
| Rate for Payer: WEA Trust Commercial |
$381.70
|
| Rate for Payer: WPS Commercial |
$514.05
|
|
|
TDAP Vaccine > 7 IM 90715
|
Professional
|
Both
|
$93.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3382847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$97.72 |
| Rate for Payer: Aetna Commercial |
$88.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.09
|
| Rate for Payer: Health EOS Commercial |
$84.63
|
| Rate for Payer: HFN Commercial |
$88.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.50
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: Preferred Network Access Commercial |
$88.35
|
| Rate for Payer: Quartz Beloit One Network |
$40.92
|
| Rate for Payer: Quartz Commercial |
$53.01
|
| Rate for Payer: The Alliance Commercial |
$46.50
|
| Rate for Payer: United Healthcare Medicaid |
$67.41
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$97.72
|
|
|
TDAP Vaccine > 7 IM 90715
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3382847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
TDAP Vaccine > 7 IM 90715
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3382847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$26.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.71
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.75
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$60.45
|
| Rate for Payer: Quartz Medicare Advantage |
$55.80
|
| Rate for Payer: The Alliance Commercial |
$372.00
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$97.72
|
|
|
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 |
$5.83 |
| Max. Negotiated Rate |
$97.72 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.71
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$97.72
|
|
|
TDAP Vaccine >7 IM 90715 VFC
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
5076614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
TDAP Vaccine >7 IM 90715 VFC
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
5076614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$97.72 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.09
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.50
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$67.41
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$97.72
|
|
|
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 |
$24.91 |
| Max. Negotiated Rate |
$424.00 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Aetna Managed Medicare |
$29.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.91
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.50
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$68.90
|
| Rate for Payer: Quartz Medicare Advantage |
$63.60
|
| Rate for Payer: The Alliance Commercial |
$424.00
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$47.07
|
|
|
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 |
$18.83 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Aetna Commercial |
$100.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$100.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.83
|
| Rate for Payer: Health EOS Commercial |
$96.46
|
| Rate for Payer: HFN Commercial |
$100.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.65
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: Preferred Network Access Commercial |
$100.70
|
| Rate for Payer: Quartz Beloit One Network |
$46.64
|
| Rate for Payer: Quartz Commercial |
$60.42
|
| Rate for Payer: The Alliance Commercial |
$53.00
|
| Rate for Payer: United Healthcare Medicaid |
$54.74
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$47.07
|
|
|
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 |
$51.94 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$63.60
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
TEETH EXTRACTION, BABY (1-6)
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960406
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTION, BABY (1-6)
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960406
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTIONS, FULL MOUTH
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960408
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTIONS, FULL MOUTH
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960408
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTIONS, MULTIPLE (1-6)
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960409
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
TEETH EXTRACTIONS, MULTIPLE (1-6)
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960409
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
TEETH EXTRACTION, WISDOM TEETH
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
