|
DX BRONCHOSCOPE/BRUSH 31623
|
Professional
|
$1,805.00
|
|
|
Service Code
|
CPT 31623
|
| Hospital Charge Code |
5619672
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$123.34 |
| Max. Negotiated Rate |
$1,714.75 |
| Rate for Payer: Aetna Commercial |
$1,714.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Aetna Managed Medicare |
$123.34
|
| Rate for Payer: Anthem Medicare Advantage |
$123.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$123.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$123.34
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,714.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$902.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.34
|
| Rate for Payer: Health EOS Commercial |
$1,642.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$448.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$123.34
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,714.75
|
| Rate for Payer: Quartz Beloit One Network |
$794.20
|
| Rate for Payer: Quartz Commercial |
$1,028.85
|
| Rate for Payer: Quartz Medicare Advantage |
$123.34
|
| Rate for Payer: The Alliance Commercial |
$524.20
|
| Rate for Payer: United Healthcare Medicaid |
$206.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$123.34
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$555.03
|
|
|
DX BRONCHOSCOPE/LAVAGE 31624
|
Professional
|
$1,877.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
3014399
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$124.94 |
| Max. Negotiated Rate |
$1,783.15 |
| Rate for Payer: Aetna Commercial |
$1,783.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.22
|
| Rate for Payer: Aetna Managed Medicare |
$124.94
|
| Rate for Payer: Anthem Medicare Advantage |
$124.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$124.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$124.94
|
| Rate for Payer: Cash Price |
$563.10
|
| Rate for Payer: Cash Price |
$563.10
|
| Rate for Payer: Cigna Commercial |
$1,783.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$938.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.94
|
| Rate for Payer: Health EOS Commercial |
$1,708.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$452.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$452.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$124.94
|
| Rate for Payer: Multiplan Commercial |
$1,501.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,783.15
|
| Rate for Payer: Quartz Beloit One Network |
$825.88
|
| Rate for Payer: Quartz Commercial |
$1,069.89
|
| Rate for Payer: Quartz Medicare Advantage |
$124.94
|
| Rate for Payer: The Alliance Commercial |
$531.00
|
| Rate for Payer: United Healthcare Medicaid |
$208.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.94
|
| Rate for Payer: WEA Trust Commercial |
$1,032.35
|
| Rate for Payer: WPS Commercial |
$562.23
|
|
|
DX BRONCHOSCOPE/WASH 31622
|
Professional
|
$1,632.00
|
|
|
Service Code
|
CPT 31622
|
| Hospital Charge Code |
3014398
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$121.98 |
| Max. Negotiated Rate |
$1,550.40 |
| Rate for Payer: Aetna Commercial |
$1,550.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,403.52
|
| Rate for Payer: Aetna Managed Medicare |
$121.98
|
| Rate for Payer: Anthem Medicare Advantage |
$121.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$121.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$121.98
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$1,550.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$816.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.98
|
| Rate for Payer: Health EOS Commercial |
$1,485.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$440.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$440.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$121.98
|
| Rate for Payer: Multiplan Commercial |
$1,305.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.40
|
| Rate for Payer: Quartz Beloit One Network |
$718.08
|
| Rate for Payer: Quartz Commercial |
$930.24
|
| Rate for Payer: Quartz Medicare Advantage |
$121.98
|
| Rate for Payer: The Alliance Commercial |
$518.42
|
| Rate for Payer: United Healthcare Medicaid |
$277.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.98
|
| Rate for Payer: WEA Trust Commercial |
$897.60
|
| Rate for Payer: WPS Commercial |
$548.91
|
|
|
DX LARYNGOSCOPY EXCL NB 31525
|
Professional
|
$1,145.00
|
|
|
Service Code
|
CPT 31525
|
| Hospital Charge Code |
3014386
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$149.08 |
| Max. Negotiated Rate |
$1,087.75 |
| Rate for Payer: Aetna Commercial |
$1,087.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$984.70
|
| Rate for Payer: Aetna Managed Medicare |
$149.08
|
| Rate for Payer: Anthem Medicare Advantage |
$149.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$149.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$149.08
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$1,087.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$572.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$149.08
|
| Rate for Payer: Health EOS Commercial |
$1,041.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$524.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$524.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$149.08
|
| Rate for Payer: Multiplan Commercial |
$916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,087.75
|
| Rate for Payer: Quartz Beloit One Network |
$503.80
|
| Rate for Payer: Quartz Commercial |
$652.65
|
| Rate for Payer: Quartz Medicare Advantage |
$149.08
|
| Rate for Payer: The Alliance Commercial |
$633.59
|
| Rate for Payer: United Healthcare Medicaid |
$198.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.08
|
| Rate for Payer: WEA Trust Commercial |
$629.75
|
| Rate for Payer: WPS Commercial |
$670.86
|
|
|
DYNACLIP BONE FIXATION SYSTEM 10MM X 10MM X 10MM 3000-00-101010
|
Facility
IP
|
$7,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226162
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,463.81 |
| Max. Negotiated Rate |
$6,503.48 |
| Rate for Payer: Aetna Commercial |
$6,362.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,746.57
|
| Rate for Payer: Cash Price |
$2,120.70
|
| Rate for Payer: Cigna Commercial |
$6,503.48
|
| Rate for Payer: Health EOS Commercial |
$6,291.41
|
| Rate for Payer: HFN Commercial |
$6,503.48
|
| Rate for Payer: Multiplan Commercial |
$5,655.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,241.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,503.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,463.81
|
| Rate for Payer: Quartz Commercial |
$4,241.40
|
| Rate for Payer: WEA Trust Commercial |
$3,887.95
|
| Rate for Payer: WPS Commercial |
$5,236.01
|
|
|
DYNACLIP BONE FIXATION SYSTEM 10MM X 10MM X 10MM 3000-00-101010
|
Facility
OP
|
$7,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226162
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,979.32 |
| Max. Negotiated Rate |
$6,503.48 |
| Rate for Payer: Aetna Commercial |
$6,362.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,079.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,979.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,594.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,534.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,393.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,746.57
|
| Rate for Payer: Cash Price |
$2,120.70
|
| Rate for Payer: Cigna Commercial |
$6,503.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,955.81
|
| Rate for Payer: Health EOS Commercial |
$6,291.41
|
| Rate for Payer: HFN Commercial |
$6,503.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,301.75
|
| Rate for Payer: Multiplan Commercial |
$5,655.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,241.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,503.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,463.81
|
| Rate for Payer: Quartz Commercial |
$4,594.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,241.40
|
| Rate for Payer: WEA Trust Commercial |
$3,887.95
|
| Rate for Payer: WPS Commercial |
$5,236.01
|
|
|
Dynamic Pro/Sup Splint
|
Facility
OP
|
$602.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
2989898
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$168.56 |
| Max. Negotiated Rate |
$2,408.00 |
| Rate for Payer: Aetna Commercial |
$541.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.72
|
| Rate for Payer: Aetna Managed Medicare |
$168.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$289.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$289.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$289.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.06
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$553.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.88
|
| Rate for Payer: Health EOS Commercial |
$535.78
|
| Rate for Payer: HFN Commercial |
$553.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$451.50
|
| Rate for Payer: Multiplan Commercial |
$481.60
|
| Rate for Payer: NAPHCARE Commercial |
$361.20
|
| Rate for Payer: Preferred Network Access Commercial |
$553.84
|
| Rate for Payer: Quartz Beloit One Network |
$294.98
|
| Rate for Payer: Quartz Commercial |
$391.30
|
| Rate for Payer: Quartz Medicare Advantage |
$361.20
|
| Rate for Payer: The Alliance Commercial |
$2,408.00
|
| Rate for Payer: WEA Trust Commercial |
$331.10
|
| Rate for Payer: WPS Commercial |
$445.90
|
|
|
Dynamic Pro/Sup Splint
|
Facility
IP
|
$602.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
2989898
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$294.98 |
| Max. Negotiated Rate |
$553.84 |
| Rate for Payer: Aetna Commercial |
$541.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.06
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$553.84
|
| Rate for Payer: Health EOS Commercial |
$535.78
|
| Rate for Payer: HFN Commercial |
$553.84
|
| Rate for Payer: Multiplan Commercial |
$481.60
|
| Rate for Payer: NAPHCARE Commercial |
$361.20
|
| Rate for Payer: Preferred Network Access Commercial |
$553.84
|
| Rate for Payer: Quartz Beloit One Network |
$294.98
|
| Rate for Payer: Quartz Commercial |
$361.20
|
| Rate for Payer: WEA Trust Commercial |
$331.10
|
| Rate for Payer: WPS Commercial |
$445.90
|
|
|
DYNAMIZATION CLIP FOR LARGE COMBINATION CLAMP 390.006
|
Facility
IP
|
$1,705.00
|
|
| Hospital Charge Code |
2966164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$835.45 |
| Max. Negotiated Rate |
$1,568.60 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,023.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
DYNAMIZATION CLIP FOR LARGE COMBINATION CLAMP 390.006
|
Facility
OP
|
$1,705.00
|
|
| Hospital Charge Code |
2966164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$477.40 |
| Max. Negotiated Rate |
$6,820.00 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Aetna Managed Medicare |
$477.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,108.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$852.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$818.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$954.12
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,278.75
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,108.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,023.00
|
| Rate for Payer: The Alliance Commercial |
$6,820.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
DYSEQUILIBRIUM
|
Facility
IP
|
$20,119.00
|
|
|
Service Code
|
MS-DRG 149
|
| Min. Negotiated Rate |
$7,237.06 |
| Max. Negotiated Rate |
$20,119.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,237.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,525.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,899.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,305.72
|
| Rate for Payer: Anthem Medicare Advantage |
$7,237.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,237.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,237.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,237.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,550.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,237.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,521.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,237.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,237.06
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,237.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,237.06
|
| Rate for Payer: NAPHCARE Commercial |
$10,855.59
|
| Rate for Payer: Quartz Medicare Advantage |
$7,237.06
|
| Rate for Payer: The Alliance Commercial |
$20,119.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,237.06
|
| Rate for Payer: United Healthcare PPO |
$11,305.29
|
| Rate for Payer: Wellcare Medicare |
$7,237.06
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Facility
OP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: United Healthcare PPO |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Professional
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$13.88
|
| Rate for Payer: Anthem Medicare Advantage |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.88
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.88
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.88
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: Quartz Medicare Advantage |
$13.88
|
| Rate for Payer: The Alliance Commercial |
$34.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.88
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$55.52
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Facility
IP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Each Additional 90472 - Admin Hep B Charge
|
Facility
OP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013440
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: United Healthcare PPO |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Each Additional 90472 - Admin Hep B Charge
|
Facility
IP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013440
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Each Additional 90472 - Admin Hep B Charge
|
Professional
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013440
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$13.88
|
| Rate for Payer: Anthem Medicare Advantage |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.88
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.88
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.88
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: Quartz Medicare Advantage |
$13.88
|
| Rate for Payer: The Alliance Commercial |
$34.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.88
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$55.52
|
|
|
Each Additional 90472 - Admin Immunization Charge
|
Professional
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
2473257
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$13.88
|
| Rate for Payer: Anthem Medicare Advantage |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.88
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.88
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.88
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: Quartz Medicare Advantage |
$13.88
|
| Rate for Payer: The Alliance Commercial |
$34.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.88
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$55.52
|
|
|
Each Additional 90472 - Admin Immunization Charge
|
Facility
IP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
2473257
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Each Additional 90472 - Admin Immunization Charge
|
Facility
OP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
2473257
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: United Healthcare PPO |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Each Additional 90472 - Pnuemococcal 23, 2 years+
|
Facility
IP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013446
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Each Additional 90472 - Pnuemococcal 23, 2 years+
|
Facility
OP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013446
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: United Healthcare PPO |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Each Additional 90472 - Pnuemococcal 23, 2 years+
|
Professional
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013446
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$13.88
|
| Rate for Payer: Anthem Medicare Advantage |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.88
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.88
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.88
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: Quartz Medicare Advantage |
$13.88
|
| Rate for Payer: The Alliance Commercial |
$34.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.88
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$55.52
|
|
|
EAPG 00001: PHOTOCHEMOTHERAPY
|
Facility
OP
|
$78.43
|
|
|
Service Code
|
EAPG 00001
|
| Min. Negotiated Rate |
$78.43 |
| Max. Negotiated Rate |
$78.43 |
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$78.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$78.43
|
|
|
EAPG 00006: LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION
|
Facility
OP
|
$242.32
|
|
|
Service Code
|
EAPG 00006
|
| Min. Negotiated Rate |
$242.32 |
| Max. Negotiated Rate |
$242.32 |
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$242.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$242.32
|
|
