|
ADJUSTMENT INSTRUMENTD HOFFMANN LIMB 4934-9-100
|
Facility
|
OP
|
$4,461.00
|
|
| Hospital Charge Code |
6206984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,299.04 |
| Max. Negotiated Rate |
$4,268.28 |
| Rate for Payer: Aetna Commercial |
$4,175.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,299.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,015.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,319.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,226.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.90
|
| Rate for Payer: Cash Price |
$1,338.30
|
| Rate for Payer: Cigna Commercial |
$4,268.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,596.30
|
| Rate for Payer: Health EOS Commercial |
$4,129.10
|
| Rate for Payer: HFN Commercial |
$4,268.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,479.58
|
| Rate for Payer: Multiplan Commercial |
$3,711.55
|
| Rate for Payer: NAPHCARE Commercial |
$2,783.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,268.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,273.33
|
| Rate for Payer: Quartz Commercial |
$3,015.64
|
| Rate for Payer: Quartz Medicare Advantage |
$2,783.66
|
| Rate for Payer: The Alliance Commercial |
$2,319.72
|
| Rate for Payer: WEA Trust Commercial |
$2,551.69
|
| Rate for Payer: WPS Commercial |
$3,436.31
|
|
|
ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYSTEM REQUIRING ANESTHESIA (EG, NEW PIN[S] OR WIRE[S] AND/OR NEW RING[S] OR BAR[S])
|
Facility
|
OP
|
$30,545.47
|
|
|
Service Code
|
CPT 20693
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,947.89 |
| Max. Negotiated Rate |
$30,545.47 |
| Rate for Payer: Aetna Managed Medicare |
$7,636.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,724.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,889.12
|
| Rate for Payer: Anthem Medicare Advantage |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,636.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,636.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,636.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,407.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,636.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,636.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,636.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,636.37
|
| Rate for Payer: NAPHCARE Commercial |
$11,454.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,636.37
|
| Rate for Payer: The Alliance Commercial |
$30,545.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,636.37
|
| Rate for Payer: United Healthcare PPO |
$8,790.08
|
| Rate for Payer: Wellcare Medicare |
$7,636.37
|
|
|
Admin All Other - Admin Flu Virus
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5542822
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.99 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.99
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$12.17
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$14.04
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Admin All Other - Admin Flu Virus
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5542822
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.23
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Admin All Other - Admin Flu Virus
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5542822
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$87.94 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$21.99
|
| Rate for Payer: Anthem Medicare Advantage |
$21.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.99
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.99
|
| Rate for Payer: Health EOS Commercial |
$17.04
|
| Rate for Payer: HFN Commercial |
$17.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.99
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$32.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.78
|
| Rate for Payer: Quartz Beloit One Network |
$8.24
|
| Rate for Payer: Quartz Commercial |
$10.67
|
| Rate for Payer: Quartz Medicare Advantage |
$21.99
|
| Rate for Payer: The Alliance Commercial |
$54.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.99
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$87.94
|
|
|
Admin Alteplase/Cathflow 36593
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
5220608
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.91 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.03
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$91.73
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
Admin Alteplase/Cathflow 36593
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
5220608
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.38 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Aetna Managed Medicare |
$347.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.38
|
| Rate for Payer: Anthem Medicare Advantage |
$347.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$347.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$347.61
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$347.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$347.61
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,293.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$347.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$347.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$347.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$347.61
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: NAPHCARE Commercial |
$521.41
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$99.37
|
| Rate for Payer: Quartz Medicare Advantage |
$347.61
|
| Rate for Payer: The Alliance Commercial |
$1,390.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$347.61
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: Wellcare Medicare |
$347.61
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
Admin Chemo Subq/IM Non-Hormonal Anti-Neoplastic
|
Facility
|
OP
|
$441.00
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
5220606
|
|
Hospital Revenue Code
|
280
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$421.95 |
| Rate for Payer: Aetna Commercial |
$412.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.43
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$298.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$229.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$220.15
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$421.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$408.19
|
| Rate for Payer: HFN Commercial |
$421.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$366.91
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$421.95
|
| Rate for Payer: Quartz Beloit One Network |
$224.73
|
| Rate for Payer: Quartz Commercial |
$298.12
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$343.98
|
| Rate for Payer: WEA Trust Commercial |
$252.25
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$339.70
|
|
|
Admin Chemo Subq/IM Non-Hormonal Anti-Neoplastic
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
5220606
|
|
Hospital Revenue Code
|
280
|
| Min. Negotiated Rate |
$224.73 |
| Max. Negotiated Rate |
$421.95 |
| Rate for Payer: Aetna Commercial |
$412.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.08
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$421.95
|
| Rate for Payer: Health EOS Commercial |
$408.19
|
| Rate for Payer: HFN Commercial |
$421.95
|
| Rate for Payer: Multiplan Commercial |
$366.91
|
| Rate for Payer: Preferred Network Access Commercial |
$421.95
|
| Rate for Payer: Quartz Beloit One Network |
$224.73
|
| Rate for Payer: Quartz Commercial |
$275.18
|
| Rate for Payer: WEA Trust Commercial |
$252.25
|
| Rate for Payer: WPS Commercial |
$339.70
|
|
|
Admin hepatitis b vaccine G0010
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3431532
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.96 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Admin hepatitis b vaccine G0010
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3431532
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Admin hepatitis b vaccine G0010
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3431532
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$24.71 |
| Max. Negotiated Rate |
$59.55 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.70
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.55
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: The Alliance Commercial |
$28.08
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Admin influenza virus vac G0008
|
Facility
|
IP
|
$12.00
|
|
| Hospital Charge Code |
3431533
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna Commercial |
$11.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.61
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.48
|
| Rate for Payer: Health EOS Commercial |
$11.11
|
| Rate for Payer: HFN Commercial |
$11.48
|
| Rate for Payer: Multiplan Commercial |
$9.98
|
| Rate for Payer: Preferred Network Access Commercial |
$11.48
|
| Rate for Payer: Quartz Beloit One Network |
$6.12
|
| Rate for Payer: Quartz Commercial |
$7.49
|
| Rate for Payer: WEA Trust Commercial |
$6.86
|
| Rate for Payer: WPS Commercial |
$9.24
|
|
|
Admin influenza virus vac G0008
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
3431533
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna Commercial |
$11.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.73
|
| Rate for Payer: Aetna Managed Medicare |
$3.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.61
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.98
|
| Rate for Payer: Health EOS Commercial |
$11.11
|
| Rate for Payer: HFN Commercial |
$11.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.36
|
| Rate for Payer: Multiplan Commercial |
$9.98
|
| Rate for Payer: NAPHCARE Commercial |
$7.49
|
| Rate for Payer: Preferred Network Access Commercial |
$11.48
|
| Rate for Payer: Quartz Beloit One Network |
$6.12
|
| Rate for Payer: Quartz Commercial |
$8.11
|
| Rate for Payer: Quartz Medicare Advantage |
$7.49
|
| Rate for Payer: The Alliance Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$6.86
|
| Rate for Payer: WPS Commercial |
$9.24
|
|
|
Admin influenza virus vac G0008
|
Professional
|
Both
|
$12.00
|
|
| Hospital Charge Code |
3431533
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Aetna Commercial |
$11.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.73
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.49
|
| Rate for Payer: Health EOS Commercial |
$11.36
|
| Rate for Payer: HFN Commercial |
$11.86
|
| Rate for Payer: Multiplan Commercial |
$9.98
|
| Rate for Payer: Preferred Network Access Commercial |
$11.86
|
| Rate for Payer: Quartz Beloit One Network |
$5.49
|
| Rate for Payer: Quartz Commercial |
$7.11
|
| Rate for Payer: The Alliance Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$6.86
|
| Rate for Payer: WPS Commercial |
$9.24
|
|
|
Admin Influenze Medicare
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT G0008
|
| Hospital Charge Code |
3970751
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
Admin Influenze Medicare
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT G0008
|
| Hospital Charge Code |
3970751
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$17.16
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
Administered - Dtap-Hep B-IPV Charge
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3013472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.11 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$137.28
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
Administered - Dtap-Hep B-IPV Charge
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3013472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.06 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Aetna Managed Medicare |
$64.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$148.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$114.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$109.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.04
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$171.60
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: NAPHCARE Commercial |
$137.28
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$148.72
|
| Rate for Payer: Quartz Medicare Advantage |
$137.28
|
| Rate for Payer: The Alliance Commercial |
$114.40
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
Administered - Dtap-Hep B-IPV Charge
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3013472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.67 |
| Max. Negotiated Rate |
$217.36 |
| Rate for Payer: Aetna Commercial |
$217.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$217.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.28
|
| Rate for Payer: Health EOS Commercial |
$208.21
|
| Rate for Payer: HFN Commercial |
$217.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$186.67
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: Preferred Network Access Commercial |
$217.36
|
| Rate for Payer: Quartz Beloit One Network |
$100.67
|
| Rate for Payer: Quartz Commercial |
$130.42
|
| Rate for Payer: The Alliance Commercial |
$114.40
|
| Rate for Payer: United Healthcare Medicaid |
$107.76
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
Administered - Hep A Adult Charge
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 90632
|
| Hospital Charge Code |
3013461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.86 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$121.06
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
Administered - Hep A Adult Charge
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
CPT 90632
|
| Hospital Charge Code |
3013461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.36 |
| Max. Negotiated Rate |
$191.67 |
| Rate for Payer: Aetna Commercial |
$191.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Aetna Managed Medicare |
$76.48
|
| Rate for Payer: Anthem Medicare Advantage |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$76.48
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$191.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.36
|
| Rate for Payer: Health EOS Commercial |
$183.60
|
| Rate for Payer: HFN Commercial |
$191.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$76.48
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$114.72
|
| Rate for Payer: Preferred Network Access Commercial |
$191.67
|
| Rate for Payer: Quartz Beloit One Network |
$88.77
|
| Rate for Payer: Quartz Commercial |
$115.00
|
| Rate for Payer: Quartz Medicare Advantage |
$76.48
|
| Rate for Payer: The Alliance Commercial |
$191.20
|
| Rate for Payer: United Healthcare Medicaid |
$89.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.48
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$183.41
|
|
|
Administered - Hep A Adult Charge
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 90632
|
| Hospital Charge Code |
3013461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.49 |
| Max. Negotiated Rate |
$305.93 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Aetna Managed Medicare |
$56.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.06
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.32
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$121.06
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$131.14
|
| Rate for Payer: Quartz Medicare Advantage |
$121.06
|
| Rate for Payer: The Alliance Commercial |
$305.93
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$183.41
|
|
|
Administered - Hep A/B Charge
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
3013465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.83 |
| Max. Negotiated Rate |
$268.86 |
| Rate for Payer: Aetna Commercial |
$263.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.33
|
| Rate for Payer: Aetna Managed Medicare |
$81.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$189.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$146.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$140.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.89
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$268.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.54
|
| Rate for Payer: Health EOS Commercial |
$260.09
|
| Rate for Payer: HFN Commercial |
$268.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$219.18
|
| Rate for Payer: Multiplan Commercial |
$233.79
|
| Rate for Payer: NAPHCARE Commercial |
$175.34
|
| Rate for Payer: Preferred Network Access Commercial |
$268.86
|
| Rate for Payer: Quartz Beloit One Network |
$143.20
|
| Rate for Payer: Quartz Commercial |
$189.96
|
| Rate for Payer: Quartz Medicare Advantage |
$175.34
|
| Rate for Payer: The Alliance Commercial |
$146.12
|
| Rate for Payer: WEA Trust Commercial |
$160.73
|
| Rate for Payer: WPS Commercial |
$216.45
|
|
|
Administered - Hep A/B Charge
|
Professional
|
Both
|
$281.00
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
3013465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.59 |
| Max. Negotiated Rate |
$277.63 |
| Rate for Payer: Aetna Commercial |
$277.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.33
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$277.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$175.34
|
| Rate for Payer: Health EOS Commercial |
$265.94
|
| Rate for Payer: HFN Commercial |
$277.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$194.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$194.05
|
| Rate for Payer: Multiplan Commercial |
$233.79
|
| Rate for Payer: Preferred Network Access Commercial |
$277.63
|
| Rate for Payer: Quartz Beloit One Network |
$128.59
|
| Rate for Payer: Quartz Commercial |
$166.58
|
| Rate for Payer: The Alliance Commercial |
$146.12
|
| Rate for Payer: United Healthcare Medicaid |
$137.73
|
| Rate for Payer: WEA Trust Commercial |
$160.73
|
| Rate for Payer: WPS Commercial |
$216.45
|
|
