|
DYNAMIZATION CLIP FOR LARGE COMBINATION CLAMP 390.006
|
Facility
|
IP
|
$1,705.00
|
|
| Hospital Charge Code |
2966164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$868.87 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
DYNAMIZATION CLIP FOR LARGE COMBINATION CLAMP 390.006
|
Facility
|
OP
|
$1,705.00
|
|
| Hospital Charge Code |
2966164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$496.50 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Aetna Managed Medicare |
$496.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,152.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$886.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$851.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$992.31
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,329.90
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,063.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,152.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,063.92
|
| Rate for Payer: The Alliance Commercial |
$886.60
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
DYSEQUILIBRIUM
|
Facility
|
IP
|
$20,923.76
|
|
|
Service Code
|
MSDRG 149
|
| Min. Negotiated Rate |
$6,262.68 |
| Max. Negotiated Rate |
$20,923.76 |
| Rate for Payer: Aetna Managed Medicare |
$6,262.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,399.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,569.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,942.26
|
| Rate for Payer: Anthem Medicare Advantage |
$6,262.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,262.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,262.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,262.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,257.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,262.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,102.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,262.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,262.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,262.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,262.68
|
| Rate for Payer: NAPHCARE Commercial |
$9,394.02
|
| Rate for Payer: Quartz Medicare Advantage |
$6,262.68
|
| Rate for Payer: The Alliance Commercial |
$20,923.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,262.68
|
| Rate for Payer: United Healthcare PPO |
$11,757.50
|
| Rate for Payer: Wellcare Medicare |
$6,262.68
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: WPS Commercial |
$63.86
|
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
|
|
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 |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
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 |
$15.72 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Each Additional 90472 - Admin Hep B Charge
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013440
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$55.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$55.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$53.00
|
| Rate for Payer: HFN Commercial |
$55.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$55.33
|
| Rate for Payer: Quartz Beloit One Network |
$25.63
|
| Rate for Payer: Quartz Commercial |
$33.20
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$63.86
|
|
|
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 |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
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 |
$16.31 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.59
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
Each Additional 90472 - Admin Immunization Charge
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
2473257
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$55.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$55.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$53.00
|
| Rate for Payer: HFN Commercial |
$55.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$55.33
|
| Rate for Payer: Quartz Beloit One Network |
$25.63
|
| Rate for Payer: Quartz Commercial |
$33.20
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$63.86
|
|
|
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 |
$16.31 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.59
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
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 |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
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 |
$15.72 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Each Additional 90472 - Pnuemococcal 23, 2 years+
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013446
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$63.86
|
|
|
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 |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
EAR AND THROAT EXAMINATION 92502
|
Professional
|
Both
|
$773.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
3015328
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.85 |
| Max. Negotiated Rate |
$763.72 |
| Rate for Payer: Aetna Commercial |
$763.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$691.37
|
| Rate for Payer: Aetna Managed Medicare |
$85.85
|
| Rate for Payer: Anthem Medicare Advantage |
$85.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$85.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$85.85
|
| Rate for Payer: Cash Price |
$231.90
|
| Rate for Payer: Cash Price |
$231.90
|
| Rate for Payer: Cigna Commercial |
$763.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$401.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.85
|
| Rate for Payer: Health EOS Commercial |
$731.57
|
| Rate for Payer: HFN Commercial |
$763.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$332.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$332.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$85.85
|
| Rate for Payer: Multiplan Commercial |
$643.14
|
| Rate for Payer: NAPHCARE Commercial |
$128.78
|
| Rate for Payer: Preferred Network Access Commercial |
$763.72
|
| Rate for Payer: Quartz Beloit One Network |
$353.72
|
| Rate for Payer: Quartz Commercial |
$458.23
|
| Rate for Payer: Quartz Medicare Advantage |
$85.85
|
| Rate for Payer: The Alliance Commercial |
$214.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$85.85
|
| Rate for Payer: WEA Trust Commercial |
$442.16
|
| Rate for Payer: WPS Commercial |
$343.41
|
|
|
Ear Culture
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$8.96
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Ear Culture
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$39.45
|
|
|
Ear Culture
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
EAR DRESSING GLASSCOCK ADULT S-1000
|
Facility
|
IP
|
$313.00
|
|
| Hospital Charge Code |
3204818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$159.50 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$195.31
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
EAR DRESSING GLASSCOCK ADULT S-1000
|
Facility
|
OP
|
$313.00
|
|
| Hospital Charge Code |
3204818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$91.15 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$91.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$211.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$162.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$156.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.17
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$244.14
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$195.31
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$211.59
|
| Rate for Payer: Quartz Medicare Advantage |
$195.31
|
| Rate for Payer: The Alliance Commercial |
$162.76
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
EAR EXAM WITH ANESTHESIA
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960001
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
EAR EXAM WITH ANESTHESIA
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960001
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
Early Sjogren's Syndrome Profile
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5455288
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$328.02 |
| Rate for Payer: Aetna Commercial |
$328.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$328.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$172.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$314.20
|
| Rate for Payer: HFN Commercial |
$328.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$328.02
|
| Rate for Payer: Quartz Beloit One Network |
$151.92
|
| Rate for Payer: Quartz Commercial |
$196.81
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Early Sjogren's Syndrome Profile
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5455288
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$169.19 |
| Max. Negotiated Rate |
$317.66 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.00
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$207.17
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
