|
diphenhydrAMINE 50 mg/mL Inj Vial [Med]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2983105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.34
|
| Rate for Payer: Aetna Managed Medicare |
$5.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.09
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.25
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: Quartz Medicare Advantage |
$11.40
|
| Rate for Payer: The Alliance Commercial |
$76.00
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$2.06
|
|
|
Diphenhydramine hcl inj <50 mg J1200
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
3523500
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.40
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
Diphenhydramine hcl inj <50 mg J1200
|
Professional
|
Both
|
$4.00
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
3523500
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.82
|
| Rate for Payer: Health EOS Commercial |
$3.64
|
| Rate for Payer: HFN Commercial |
$3.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3.80
|
| Rate for Payer: Quartz Beloit One Network |
$1.76
|
| Rate for Payer: Quartz Commercial |
$2.28
|
| Rate for Payer: The Alliance Commercial |
$2.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.80
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.06
|
|
|
Diphenhydramine hcl inj <50 mg J1200
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
3523500
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Aetna Managed Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.09
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2.40
|
| Rate for Payer: The Alliance Commercial |
$16.00
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
Diphtheria and Tetanus Antitoxiod
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
4510630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.69 |
| Max. Negotiated Rate |
$122.55 |
| Rate for Payer: Aetna Commercial |
$122.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$122.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.40
|
| Rate for Payer: Health EOS Commercial |
$117.39
|
| Rate for Payer: HFN Commercial |
$122.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.69
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$122.55
|
| Rate for Payer: Quartz Beloit One Network |
$56.76
|
| Rate for Payer: Quartz Commercial |
$73.53
|
| Rate for Payer: The Alliance Commercial |
$64.50
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Diphtheria and Tetanus Antitoxiod
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
4510630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$15.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.25
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$15.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.21
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.21
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.21
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.21
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.21
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.82
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$15.21
|
| Rate for Payer: The Alliance Commercial |
$60.84
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.21
|
| Rate for Payer: United Healthcare PPO |
$96.75
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: Wellcare Medicare |
$15.21
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Diphtheria and Tetanus Antitoxiod
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
4510630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Diphtheria Antibody
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
977926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.69 |
| Max. Negotiated Rate |
$231.80 |
| Rate for Payer: Aetna Commercial |
$231.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$231.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.40
|
| Rate for Payer: Health EOS Commercial |
$222.04
|
| Rate for Payer: HFN Commercial |
$231.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.69
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.80
|
| Rate for Payer: Quartz Beloit One Network |
$107.36
|
| Rate for Payer: Quartz Commercial |
$139.08
|
| Rate for Payer: The Alliance Commercial |
$122.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
Diphtheria Antibody
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
977926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$119.56 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$146.40
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$146.40
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
Diphtheria Antibody
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
977926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Aetna Managed Medicare |
$15.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.25
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$15.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.21
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.54
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.21
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.21
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.21
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.21
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.82
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$158.60
|
| Rate for Payer: Quartz Medicare Advantage |
$15.21
|
| Rate for Payer: The Alliance Commercial |
$60.84
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.21
|
| Rate for Payer: United Healthcare PPO |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: Wellcare Medicare |
$15.21
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
diphth/haemophilus/pertussis/tetanus/polio
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
741863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
diphth/haemophilus/pertussis/tetanus/polio
|
Professional
|
Both
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
741863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$270.75 |
| Rate for Payer: Aetna Commercial |
$270.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$270.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.00
|
| Rate for Payer: Health EOS Commercial |
$259.35
|
| Rate for Payer: HFN Commercial |
$270.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.58
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$270.75
|
| Rate for Payer: Quartz Beloit One Network |
$125.40
|
| Rate for Payer: Quartz Commercial |
$162.45
|
| Rate for Payer: The Alliance Commercial |
$142.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
diphth/haemophilus/pertussis/tetanus/polio
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
741863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$1,140.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM 90700 - VFC
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
5949633
|
|
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
|
|
|
DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM 90700 - VFC
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
5949633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$83.32 |
| 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: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| 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 |
$15.43
|
|
|
DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM 90700 - VFC
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
5949633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$43.16 |
| 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 |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.16
|
| 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 |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
Direct Admit Hospital Observ
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
3791433
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.91 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$35.40
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
Direct Admit Hospital Observ
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
3791433
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.32 |
| Max. Negotiated Rate |
$2,539.48 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Aetna Managed Medicare |
$634.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.32
|
| Rate for Payer: Anthem Medicare Advantage |
$634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$634.87
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$634.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$634.87
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,361.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$634.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$634.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$634.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$634.87
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$952.30
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$38.35
|
| Rate for Payer: Quartz Medicare Advantage |
$634.87
|
| Rate for Payer: The Alliance Commercial |
$2,539.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$634.87
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: Wellcare Medicare |
$634.87
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
Direct Antiglobulin Test
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$117.76 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$76.80
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Direct Antiglobulin Test
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.36
|
| Rate for Payer: Anthem Medicaid |
$5.57
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
| Rate for Payer: Dean Health Medicaid |
$5.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicaid |
$5.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.57
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$83.20
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicaid |
$5.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WMAP Medicaid |
$5.57
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Direct Antiglobulin Test Cord
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
985763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.36
|
| Rate for Payer: Anthem Medicaid |
$5.57
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
| Rate for Payer: Dean Health Medicaid |
$5.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicaid |
$5.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.57
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$83.20
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicaid |
$5.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WMAP Medicaid |
$5.57
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Direct Antiglobulin Test Cord
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
985763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$117.76 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$76.80
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Direct Antiglobulin Test Heel
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
985764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.36
|
| Rate for Payer: Anthem Medicaid |
$5.57
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
| Rate for Payer: Dean Health Medicaid |
$5.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicaid |
$5.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.57
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$83.20
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicaid |
$5.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WMAP Medicaid |
$5.57
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Direct Antiglobulin Test Heel
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
985764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$117.76 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$76.80
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY
|
Facility
|
OP
|
$21,726.56
|
|
|
Service Code
|
CPT 35045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$21,726.56 |
| Rate for Payer: Aetna Managed Medicare |
$5,431.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$5,431.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,431.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,431.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,431.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,431.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,205.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,431.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,431.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,431.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,431.64
|
| Rate for Payer: NAPHCARE Commercial |
$8,147.46
|
| Rate for Payer: Quartz Medicare Advantage |
$5,431.64
|
| Rate for Payer: The Alliance Commercial |
$21,726.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,431.64
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: Wellcare Medicare |
$5,431.64
|
|
