|
DTAP-HIB-IP Vaccine, IM 90698
|
Professional
|
Both
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3376930
|
|
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
|
|
|
DTAP-HIB-IP Vaccine, IM 90698
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3376930
|
|
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
|
|
|
DTAP-HIB-IP Vaccine, IM 90698
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3376930
|
|
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
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3455576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.48 |
| Max. Negotiated Rate |
$664.00 |
| Rate for Payer: Aetna Commercial |
$149.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.76
|
| Rate for Payer: Aetna Managed Medicare |
$46.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$107.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.98
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.89
|
| Rate for Payer: Health EOS Commercial |
$147.74
|
| Rate for Payer: HFN Commercial |
$152.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.50
|
| Rate for Payer: Multiplan Commercial |
$132.80
|
| Rate for Payer: NAPHCARE Commercial |
$99.60
|
| Rate for Payer: Preferred Network Access Commercial |
$152.72
|
| Rate for Payer: Quartz Beloit One Network |
$81.34
|
| Rate for Payer: Quartz Commercial |
$107.90
|
| Rate for Payer: Quartz Medicare Advantage |
$99.60
|
| Rate for Payer: The Alliance Commercial |
$664.00
|
| Rate for Payer: WEA Trust Commercial |
$91.30
|
| Rate for Payer: WPS Commercial |
$122.96
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696
|
Professional
|
Both
|
$166.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3455576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$157.70 |
| Rate for Payer: Aetna Commercial |
$157.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.76
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$157.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.60
|
| Rate for Payer: Health EOS Commercial |
$151.06
|
| Rate for Payer: HFN Commercial |
$157.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.84
|
| Rate for Payer: Multiplan Commercial |
$132.80
|
| Rate for Payer: Preferred Network Access Commercial |
$157.70
|
| Rate for Payer: Quartz Beloit One Network |
$73.04
|
| Rate for Payer: Quartz Commercial |
$94.62
|
| Rate for Payer: The Alliance Commercial |
$83.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$91.30
|
| Rate for Payer: WPS Commercial |
$122.96
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3455576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.34 |
| Max. Negotiated Rate |
$152.72 |
| Rate for Payer: Aetna Commercial |
$149.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.98
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: Health EOS Commercial |
$147.74
|
| Rate for Payer: HFN Commercial |
$152.72
|
| Rate for Payer: Multiplan Commercial |
$132.80
|
| Rate for Payer: NAPHCARE Commercial |
$99.60
|
| Rate for Payer: Preferred Network Access Commercial |
$152.72
|
| Rate for Payer: Quartz Beloit One Network |
$81.34
|
| Rate for Payer: Quartz Commercial |
$99.60
|
| Rate for Payer: WEA Trust Commercial |
$91.30
|
| Rate for Payer: WPS Commercial |
$122.96
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696 VFC Charge
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
5084633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$107.84 |
| 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 |
$107.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.84
|
| 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
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696 VFC Charge
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
5084633
|
|
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
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696 VFC Charge
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
5084633
|
|
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
|
|
|
DTAP Vaccine, <7 Yrs, IM 90700
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3455573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$29.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$63.00
|
| Rate for Payer: The Alliance Commercial |
$420.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
DTAP Vaccine, <7 Yrs, IM 90700
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3455573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.00
|
| Rate for Payer: Health EOS Commercial |
$95.55
|
| Rate for Payer: HFN Commercial |
$99.75
|
| 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 |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$99.75
|
| Rate for Payer: Quartz Beloit One Network |
$46.20
|
| Rate for Payer: Quartz Commercial |
$59.85
|
| Rate for Payer: The Alliance Commercial |
$52.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
DTAP Vaccine, <7 Yrs, IM 90700
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3455573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
DTIC-Dome 100 mg Charge
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2958922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Aetna Managed Medicare |
$24.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.88
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$56.55
|
| Rate for Payer: Quartz Medicare Advantage |
$52.20
|
| Rate for Payer: The Alliance Commercial |
$348.00
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$9.22
|
|
|
DTIC-Dome 100 mg Charge
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2958922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$52.20
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
DTIC-Dome 100 mg Charge
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2958922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Aetna Commercial |
$82.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$82.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.69
|
| Rate for Payer: Health EOS Commercial |
$79.17
|
| Rate for Payer: HFN Commercial |
$82.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.42
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: Preferred Network Access Commercial |
$82.65
|
| Rate for Payer: Quartz Beloit One Network |
$38.28
|
| Rate for Payer: Quartz Commercial |
$49.59
|
| Rate for Payer: The Alliance Commercial |
$43.50
|
| Rate for Payer: United Healthcare Medicaid |
$3.69
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$9.22
|
|
|
Dual Lead Pacemaker 9328026
|
Professional
|
Both
|
$578.00
|
|
|
Service Code
|
CPT 93280 26
|
| Hospital Charge Code |
3147557
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$131.10 |
| Max. Negotiated Rate |
$549.10 |
| Rate for Payer: Aetna Commercial |
$549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.08
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$549.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$289.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.80
|
| Rate for Payer: Health EOS Commercial |
$525.98
|
| Rate for Payer: HFN Commercial |
$549.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.10
|
| Rate for Payer: Multiplan Commercial |
$462.40
|
| Rate for Payer: Preferred Network Access Commercial |
$549.10
|
| Rate for Payer: Quartz Beloit One Network |
$254.32
|
| Rate for Payer: Quartz Commercial |
$329.46
|
| Rate for Payer: The Alliance Commercial |
$289.00
|
| Rate for Payer: WEA Trust Commercial |
$317.90
|
| Rate for Payer: WPS Commercial |
$428.12
|
|
|
Dual Lead Pacemaker System 93280
|
Professional
|
Both
|
$578.00
|
|
|
Service Code
|
CPT 93280
|
| Hospital Charge Code |
3927354
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.65 |
| Max. Negotiated Rate |
$549.10 |
| Rate for Payer: Aetna Commercial |
$549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.08
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$549.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.80
|
| Rate for Payer: Health EOS Commercial |
$525.98
|
| Rate for Payer: HFN Commercial |
$549.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$267.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$267.22
|
| Rate for Payer: Multiplan Commercial |
$462.40
|
| Rate for Payer: Preferred Network Access Commercial |
$549.10
|
| Rate for Payer: Quartz Beloit One Network |
$254.32
|
| Rate for Payer: Quartz Commercial |
$329.46
|
| Rate for Payer: The Alliance Commercial |
$289.00
|
| Rate for Payer: United Healthcare Medicaid |
$49.65
|
| Rate for Payer: WEA Trust Commercial |
$317.90
|
| Rate for Payer: WPS Commercial |
$428.12
|
|
|
DUAL MOBILITY BEARING ARTICULATION HIP SYSTEM 28MM HEAD SZ 38MM BEARING C EP-200144
|
Facility
|
IP
|
$6,306.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,089.94 |
| Max. Negotiated Rate |
$5,801.52 |
| Rate for Payer: Aetna Commercial |
$5,675.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,423.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,342.18
|
| Rate for Payer: Cash Price |
$1,891.80
|
| Rate for Payer: Cigna Commercial |
$5,801.52
|
| Rate for Payer: Health EOS Commercial |
$5,612.34
|
| Rate for Payer: HFN Commercial |
$5,801.52
|
| Rate for Payer: Multiplan Commercial |
$5,044.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,783.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,801.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,089.94
|
| Rate for Payer: Quartz Commercial |
$3,783.60
|
| Rate for Payer: WEA Trust Commercial |
$3,468.30
|
| Rate for Payer: WPS Commercial |
$4,670.85
|
|
|
DUAL MOBILITY BEARING ARTICULATION HIP SYSTEM 28MM HEAD SZ 38MM BEARING C EP-200144
|
Facility
|
OP
|
$6,306.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,765.68 |
| Max. Negotiated Rate |
$25,224.00 |
| Rate for Payer: Aetna Commercial |
$5,675.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,423.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,765.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,098.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,153.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,026.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,342.18
|
| Rate for Payer: Cash Price |
$1,891.80
|
| Rate for Payer: Cigna Commercial |
$5,801.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,528.84
|
| Rate for Payer: Health EOS Commercial |
$5,612.34
|
| Rate for Payer: HFN Commercial |
$5,801.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,729.50
|
| Rate for Payer: Multiplan Commercial |
$5,044.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,783.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,801.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,089.94
|
| Rate for Payer: Quartz Commercial |
$4,098.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,783.60
|
| Rate for Payer: The Alliance Commercial |
$25,224.00
|
| Rate for Payer: WEA Trust Commercial |
$3,468.30
|
| Rate for Payer: WPS Commercial |
$4,670.85
|
|
|
Dual Sheath Snare Retrieval Kit
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
4534612
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,641.50 |
| Max. Negotiated Rate |
$3,082.00 |
| Rate for Payer: Aetna Commercial |
$3,015.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,881.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,775.50
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,082.00
|
| Rate for Payer: Health EOS Commercial |
$2,981.50
|
| Rate for Payer: HFN Commercial |
$3,082.00
|
| Rate for Payer: Multiplan Commercial |
$2,680.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,010.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,082.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,641.50
|
| Rate for Payer: Quartz Commercial |
$2,010.00
|
| Rate for Payer: WEA Trust Commercial |
$1,842.50
|
| Rate for Payer: WPS Commercial |
$2,481.34
|
|
|
Dual Sheath Snare Retrieval Kit
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
4534612
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$938.00 |
| Max. Negotiated Rate |
$13,400.00 |
| Rate for Payer: Aetna Commercial |
$3,015.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,881.00
|
| Rate for Payer: Aetna Managed Medicare |
$938.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,177.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,675.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,608.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,775.50
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,082.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,874.66
|
| Rate for Payer: Health EOS Commercial |
$2,981.50
|
| Rate for Payer: HFN Commercial |
$3,082.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,512.50
|
| Rate for Payer: Multiplan Commercial |
$2,680.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,010.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,082.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,641.50
|
| Rate for Payer: Quartz Commercial |
$2,177.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,010.00
|
| Rate for Payer: The Alliance Commercial |
$13,400.00
|
| Rate for Payer: WEA Trust Commercial |
$1,842.50
|
| Rate for Payer: WPS Commercial |
$2,481.34
|
|
|
Duloxetine Level (Cymbalta)
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3813052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$397.44 |
| Rate for Payer: Aetna Commercial |
$388.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.52
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$397.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$241.75
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$384.48
|
| Rate for Payer: HFN Commercial |
$397.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$345.60
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$397.44
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$211.68
|
| Rate for Payer: Quartz Commercial |
$280.80
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$237.60
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$319.98
|
|
|
Duloxetine Level (Cymbalta)
|
Professional
|
Both
|
$432.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3813052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.52
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$410.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$216.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$259.20
|
| Rate for Payer: Health EOS Commercial |
$393.12
|
| Rate for Payer: HFN Commercial |
$410.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$410.40
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$246.24
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$237.60
|
| Rate for Payer: WPS Commercial |
$319.98
|
|
|
Duloxetine Level (Cymbalta)
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3813052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$211.68 |
| Max. Negotiated Rate |
$397.44 |
| Rate for Payer: Aetna Commercial |
$388.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.96
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$397.44
|
| Rate for Payer: Health EOS Commercial |
$384.48
|
| Rate for Payer: HFN Commercial |
$397.44
|
| Rate for Payer: Multiplan Commercial |
$345.60
|
| Rate for Payer: NAPHCARE Commercial |
$259.20
|
| Rate for Payer: Preferred Network Access Commercial |
$397.44
|
| Rate for Payer: Quartz Beloit One Network |
$211.68
|
| Rate for Payer: Quartz Commercial |
$259.20
|
| Rate for Payer: WEA Trust Commercial |
$237.60
|
| Rate for Payer: WPS Commercial |
$319.98
|
|
|
DUODERM 6X7 W/BORDER SIGNAL 403332
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2963774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$612.00 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Aetna Managed Medicare |
$42.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.62
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.75
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$99.45
|
| Rate for Payer: Quartz Medicare Advantage |
$91.80
|
| Rate for Payer: The Alliance Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
