|
DILATOR 9fr
|
Facility
|
IP
|
$260.00
|
|
| Hospital Charge Code |
2970838
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.50 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$162.24
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATOR AAA
|
Facility
|
OP
|
$1,464.00
|
|
| Hospital Charge Code |
2972290
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$426.32 |
| Max. Negotiated Rate |
$1,400.76 |
| Rate for Payer: Aetna Commercial |
$1,370.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,309.40
|
| Rate for Payer: Aetna Managed Medicare |
$426.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$989.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$761.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$730.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$806.96
|
| Rate for Payer: Cash Price |
$439.20
|
| Rate for Payer: Cigna Commercial |
$1,400.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$852.05
|
| Rate for Payer: Health EOS Commercial |
$1,355.08
|
| Rate for Payer: HFN Commercial |
$1,400.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,141.92
|
| Rate for Payer: Multiplan Commercial |
$1,218.05
|
| Rate for Payer: NAPHCARE Commercial |
$913.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,400.76
|
| Rate for Payer: Quartz Beloit One Network |
$746.05
|
| Rate for Payer: Quartz Commercial |
$989.66
|
| Rate for Payer: Quartz Medicare Advantage |
$913.54
|
| Rate for Payer: The Alliance Commercial |
$761.28
|
| Rate for Payer: WEA Trust Commercial |
$837.41
|
| Rate for Payer: WPS Commercial |
$1,127.72
|
|
|
DILATOR AAA
|
Facility
|
IP
|
$1,464.00
|
|
| Hospital Charge Code |
2972290
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$746.05 |
| Max. Negotiated Rate |
$1,400.76 |
| Rate for Payer: Aetna Commercial |
$1,370.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,309.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$806.96
|
| Rate for Payer: Cash Price |
$439.20
|
| Rate for Payer: Cigna Commercial |
$1,400.76
|
| Rate for Payer: Health EOS Commercial |
$1,355.08
|
| Rate for Payer: HFN Commercial |
$1,400.76
|
| Rate for Payer: Multiplan Commercial |
$1,218.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,400.76
|
| Rate for Payer: Quartz Beloit One Network |
$746.05
|
| Rate for Payer: Quartz Commercial |
$913.54
|
| Rate for Payer: WEA Trust Commercial |
$837.41
|
| Rate for Payer: WPS Commercial |
$1,127.72
|
|
|
DILATORS 14FR
|
Facility
|
OP
|
$260.00
|
|
| Hospital Charge Code |
2970841
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.71 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Aetna Managed Medicare |
$75.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$175.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.32
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.80
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: NAPHCARE Commercial |
$162.24
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$175.76
|
| Rate for Payer: Quartz Medicare Advantage |
$162.24
|
| Rate for Payer: The Alliance Commercial |
$135.20
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATORS 14FR
|
Facility
|
IP
|
$260.00
|
|
| Hospital Charge Code |
2970841
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.50 |
| Max. Negotiated Rate |
$248.77 |
| Rate for Payer: Aetna Commercial |
$243.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.31
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$248.77
|
| Rate for Payer: Health EOS Commercial |
$240.66
|
| Rate for Payer: HFN Commercial |
$248.77
|
| Rate for Payer: Multiplan Commercial |
$216.32
|
| Rate for Payer: Preferred Network Access Commercial |
$248.77
|
| Rate for Payer: Quartz Beloit One Network |
$132.50
|
| Rate for Payer: Quartz Commercial |
$162.24
|
| Rate for Payer: WEA Trust Commercial |
$148.72
|
| Rate for Payer: WPS Commercial |
$200.28
|
|
|
DILATOR/SHEATH SET 8/10 M0062601200
|
Facility
|
OP
|
$992.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5415301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$288.87 |
| Max. Negotiated Rate |
$949.15 |
| Rate for Payer: Aetna Commercial |
$928.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$887.24
|
| Rate for Payer: Aetna Managed Medicare |
$288.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$670.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$515.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$495.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.79
|
| Rate for Payer: Cash Price |
$297.60
|
| Rate for Payer: Cigna Commercial |
$949.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$577.34
|
| Rate for Payer: Health EOS Commercial |
$918.20
|
| Rate for Payer: HFN Commercial |
$949.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$773.76
|
| Rate for Payer: Multiplan Commercial |
$825.34
|
| Rate for Payer: NAPHCARE Commercial |
$619.01
|
| Rate for Payer: Preferred Network Access Commercial |
$949.15
|
| Rate for Payer: Quartz Beloit One Network |
$505.52
|
| Rate for Payer: Quartz Commercial |
$670.59
|
| Rate for Payer: Quartz Medicare Advantage |
$619.01
|
| Rate for Payer: The Alliance Commercial |
$515.84
|
| Rate for Payer: WEA Trust Commercial |
$567.42
|
| Rate for Payer: WPS Commercial |
$764.14
|
|
|
DILATOR/SHEATH SET 8/10 M0062601200
|
Facility
|
IP
|
$992.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5415301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$505.52 |
| Max. Negotiated Rate |
$949.15 |
| Rate for Payer: Aetna Commercial |
$928.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$887.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.79
|
| Rate for Payer: Cash Price |
$297.60
|
| Rate for Payer: Cigna Commercial |
$949.15
|
| Rate for Payer: Health EOS Commercial |
$918.20
|
| Rate for Payer: HFN Commercial |
$949.15
|
| Rate for Payer: Multiplan Commercial |
$825.34
|
| Rate for Payer: Preferred Network Access Commercial |
$949.15
|
| Rate for Payer: Quartz Beloit One Network |
$505.52
|
| Rate for Payer: Quartz Commercial |
$619.01
|
| Rate for Payer: WEA Trust Commercial |
$567.42
|
| Rate for Payer: WPS Commercial |
$764.14
|
|
|
diphenhydrAMINE 50 mg/mL Inj Vial [Med]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2983105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.47
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.18
|
| Rate for Payer: Health EOS Commercial |
$17.59
|
| Rate for Payer: HFN Commercial |
$18.18
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: Preferred Network Access Commercial |
$18.18
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$11.86
|
| Rate for Payer: WEA Trust Commercial |
$10.87
|
| Rate for Payer: WPS Commercial |
$14.64
|
|
|
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 |
$1.13 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.99
|
| Rate for Payer: Aetna Managed Medicare |
$5.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.47
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.13
|
| Rate for Payer: Health EOS Commercial |
$17.59
|
| Rate for Payer: HFN Commercial |
$18.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.82
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: NAPHCARE Commercial |
$11.86
|
| Rate for Payer: Preferred Network Access Commercial |
$18.18
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.84
|
| Rate for Payer: Quartz Medicare Advantage |
$11.86
|
| Rate for Payer: The Alliance Commercial |
$2.95
|
| Rate for Payer: WEA Trust Commercial |
$10.87
|
| Rate for Payer: WPS Commercial |
$2.14
|
|
|
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 |
$2.04 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Health EOS Commercial |
$3.70
|
| Rate for Payer: HFN Commercial |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: Preferred Network Access Commercial |
$3.83
|
| Rate for Payer: Quartz Beloit One Network |
$2.04
|
| Rate for Payer: Quartz Commercial |
$2.50
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$3.08
|
|
|
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 |
$1.13 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Aetna Managed Medicare |
$1.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.13
|
| Rate for Payer: Health EOS Commercial |
$3.70
|
| Rate for Payer: HFN Commercial |
$3.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: NAPHCARE Commercial |
$2.50
|
| Rate for Payer: Preferred Network Access Commercial |
$3.83
|
| Rate for Payer: Quartz Beloit One Network |
$2.04
|
| Rate for Payer: Quartz Commercial |
$2.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2.50
|
| Rate for Payer: The Alliance Commercial |
$2.95
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$3.08
|
|
|
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 |
$0.74 |
| Max. Negotiated Rate |
$3.95 |
| Rate for Payer: Aetna Commercial |
$3.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.74
|
| Rate for Payer: Anthem Medicare Advantage |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.74
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.86
|
| Rate for Payer: Health EOS Commercial |
$3.79
|
| Rate for Payer: HFN Commercial |
$3.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: NAPHCARE Commercial |
$1.11
|
| Rate for Payer: Preferred Network Access Commercial |
$3.95
|
| Rate for Payer: Quartz Beloit One Network |
$1.83
|
| Rate for Payer: Quartz Commercial |
$2.37
|
| Rate for Payer: Quartz Medicare Advantage |
$0.74
|
| Rate for Payer: The Alliance Commercial |
$2.03
|
| Rate for Payer: United Healthcare Medicaid |
$0.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.74
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$2.14
|
|
|
Diphtheria and Tetanus Antitoxiod
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
4510630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Diphtheria and Tetanus Antitoxiod
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
4510630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$127.45 |
| Rate for Payer: Aetna Commercial |
$127.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$15.82
|
| Rate for Payer: Anthem Medicare Advantage |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.82
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$127.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.82
|
| Rate for Payer: Health EOS Commercial |
$122.09
|
| Rate for Payer: HFN Commercial |
$127.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.82
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$23.73
|
| Rate for Payer: Preferred Network Access Commercial |
$127.45
|
| Rate for Payer: Quartz Beloit One Network |
$59.03
|
| Rate for Payer: Quartz Commercial |
$76.47
|
| Rate for Payer: Quartz Medicare Advantage |
$15.82
|
| Rate for Payer: The Alliance Commercial |
$62.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.82
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$69.60
|
|
|
Diphtheria and Tetanus Antitoxiod
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
4510630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$15.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.26
|
| Rate for Payer: Anthem Medicare Advantage |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.82
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.82
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.82
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$23.73
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$15.82
|
| Rate for Payer: The Alliance Commercial |
$63.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.82
|
| Rate for Payer: United Healthcare PPO |
$100.62
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: Wellcare Medicare |
$15.82
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Diphtheria Antibody
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
977926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$241.07 |
| Rate for Payer: Aetna Commercial |
$241.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Aetna Managed Medicare |
$15.82
|
| Rate for Payer: Anthem Medicare Advantage |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.82
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$241.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$126.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.82
|
| Rate for Payer: Health EOS Commercial |
$230.92
|
| Rate for Payer: HFN Commercial |
$241.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.82
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$23.73
|
| Rate for Payer: Preferred Network Access Commercial |
$241.07
|
| Rate for Payer: Quartz Beloit One Network |
$111.65
|
| Rate for Payer: Quartz Commercial |
$144.64
|
| Rate for Payer: Quartz Medicare Advantage |
$15.82
|
| Rate for Payer: The Alliance Commercial |
$62.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.82
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$69.60
|
|
|
Diphtheria Antibody
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
977926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.34 |
| Max. Negotiated Rate |
$233.46 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.49
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$152.26
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
Diphtheria Antibody
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 86648
|
| Hospital Charge Code |
977926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$233.46 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Aetna Managed Medicare |
$15.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.26
|
| Rate for Payer: Anthem Medicare Advantage |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.82
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.82
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.82
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$23.73
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$164.94
|
| Rate for Payer: Quartz Medicare Advantage |
$15.82
|
| Rate for Payer: The Alliance Commercial |
$63.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.82
|
| Rate for Payer: United Healthcare PPO |
$190.32
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: Wellcare Medicare |
$15.82
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
diphth/haemophilus/pertussis/tetanus/polio
|
Professional
|
Both
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
741863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.86 |
| Max. Negotiated Rate |
$281.58 |
| Rate for Payer: Aetna Commercial |
$281.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$281.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$124.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.84
|
| Rate for Payer: Health EOS Commercial |
$269.72
|
| Rate for Payer: HFN Commercial |
$281.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$195.08
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$281.58
|
| Rate for Payer: Quartz Beloit One Network |
$130.42
|
| Rate for Payer: Quartz Commercial |
$168.95
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: United Healthcare Medicaid |
$124.86
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
diphth/haemophilus/pertussis/tetanus/polio
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
741863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
diphth/haemophilus/pertussis/tetanus/polio
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
741863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
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 |
$10.61 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$9.53 |
| Max. Negotiated Rate |
$44.89 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.00
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.89
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: United Healthcare Medicaid |
$31.61
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$6.07 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
Direct Admit Hospital Observ
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
3791433
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.07 |
| Max. Negotiated Rate |
$56.45 |
| Rate for Payer: Aetna Commercial |
$55.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.52
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.45
|
| Rate for Payer: Health EOS Commercial |
$54.61
|
| Rate for Payer: HFN Commercial |
$56.45
|
| Rate for Payer: Multiplan Commercial |
$49.09
|
| Rate for Payer: Preferred Network Access Commercial |
$56.45
|
| Rate for Payer: Quartz Beloit One Network |
$30.07
|
| Rate for Payer: Quartz Commercial |
$36.82
|
| Rate for Payer: WEA Trust Commercial |
$33.75
|
| Rate for Payer: WPS Commercial |
$45.45
|
|
