|
Flublok (0.5 ml) 90682
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
CPT 90682
|
| Hospital Charge Code |
5983679
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$183.51 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Aetna Managed Medicare |
$11.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.11
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$27.30
|
| Rate for Payer: Quartz Medicare Advantage |
$25.20
|
| Rate for Payer: The Alliance Commercial |
$168.00
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$183.51
|
|
|
Flucelvax (0.5ml) (Dialysis) 90674
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
6219912
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Aetna Managed Medicare |
$16.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.21
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$39.00
|
| Rate for Payer: Quartz Medicare Advantage |
$36.00
|
| Rate for Payer: The Alliance Commercial |
$240.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$85.43
|
|
|
Flucelvax (0.5ml) (Dialysis) 90674
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
6219912
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$55.20 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$44.44
|
|
|
Flucelvax (0.5ml) - Flu Virus, Inactivated Charge
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
6210852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$55.20 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$44.44
|
|
|
Flucelvax (0.5ml) - Flu Virus, Inactivated Charge
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
6210852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Aetna Managed Medicare |
$16.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.21
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$39.00
|
| Rate for Payer: Quartz Medicare Advantage |
$36.00
|
| Rate for Payer: The Alliance Commercial |
$240.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$85.43
|
|
|
Flucelvax (0.5ml) - Flu Virus, Inactivated Charge
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
6210852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$85.43 |
| Rate for Payer: Aetna Commercial |
$57.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.17
|
| Rate for Payer: Health EOS Commercial |
$54.60
|
| Rate for Payer: HFN Commercial |
$57.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.68
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$57.00
|
| Rate for Payer: Quartz Beloit One Network |
$26.40
|
| Rate for Payer: Quartz Commercial |
$34.20
|
| Rate for Payer: The Alliance Commercial |
$30.00
|
| Rate for Payer: United Healthcare Medicaid |
$49.17
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$85.43
|
|
|
Flucelvax (0.5ml) (Peritoneal) 90674
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
6219913
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$55.20 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$44.44
|
|
|
Flucelvax (0.5ml) (Peritoneal) 90674
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
6219913
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Aetna Managed Medicare |
$16.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.21
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$39.00
|
| Rate for Payer: Quartz Medicare Advantage |
$36.00
|
| Rate for Payer: The Alliance Commercial |
$240.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$85.43
|
|
|
Fludara 50 mg Charge
|
Facility
|
OP
|
$1,497.00
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
2958952
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.97 |
| Max. Negotiated Rate |
$1,377.24 |
| Rate for Payer: Aetna Commercial |
$1,347.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,287.42
|
| Rate for Payer: Aetna Managed Medicare |
$173.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$973.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$748.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$718.56
|
| Rate for Payer: Anthem Medicare Advantage |
$173.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$793.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$173.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$173.97
|
| Rate for Payer: Cash Price |
$449.10
|
| Rate for Payer: Cash Price |
$449.10
|
| Rate for Payer: Cigna Commercial |
$1,377.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$173.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$173.97
|
| Rate for Payer: Health EOS Commercial |
$1,332.33
|
| Rate for Payer: HFN Commercial |
$1,377.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$647.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$173.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$173.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$173.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$173.97
|
| Rate for Payer: Multiplan Commercial |
$1,197.60
|
| Rate for Payer: NAPHCARE Commercial |
$260.95
|
| Rate for Payer: Preferred Network Access Commercial |
$1,377.24
|
| Rate for Payer: Quartz Beloit One Network |
$733.53
|
| Rate for Payer: Quartz Commercial |
$973.05
|
| Rate for Payer: Quartz Medicare Advantage |
$173.97
|
| Rate for Payer: The Alliance Commercial |
$695.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$173.97
|
| Rate for Payer: WEA Trust Commercial |
$823.35
|
| Rate for Payer: Wellcare Medicare |
$173.97
|
| Rate for Payer: WPS Commercial |
$477.24
|
|
|
Fludara 50 mg Charge
|
Facility
|
IP
|
$1,497.00
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
2958952
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$733.53 |
| Max. Negotiated Rate |
$1,377.24 |
| Rate for Payer: Aetna Commercial |
$1,347.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,287.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$793.41
|
| Rate for Payer: Cash Price |
$449.10
|
| Rate for Payer: Cigna Commercial |
$1,377.24
|
| Rate for Payer: Health EOS Commercial |
$1,332.33
|
| Rate for Payer: HFN Commercial |
$1,377.24
|
| Rate for Payer: Multiplan Commercial |
$1,197.60
|
| Rate for Payer: NAPHCARE Commercial |
$898.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,377.24
|
| Rate for Payer: Quartz Beloit One Network |
$733.53
|
| Rate for Payer: Quartz Commercial |
$898.20
|
| Rate for Payer: WEA Trust Commercial |
$823.35
|
| Rate for Payer: WPS Commercial |
$1,108.83
|
|
|
Fludara 50 mg Charge
|
Professional
|
Both
|
$1,497.00
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
2958952
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.76 |
| Max. Negotiated Rate |
$1,422.15 |
| Rate for Payer: Aetna Commercial |
$1,422.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,287.42
|
| Rate for Payer: Cash Price |
$449.10
|
| Rate for Payer: Cash Price |
$449.10
|
| Rate for Payer: Cigna Commercial |
$1,422.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$173.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.90
|
| Rate for Payer: Health EOS Commercial |
$1,362.27
|
| Rate for Payer: HFN Commercial |
$1,422.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.76
|
| Rate for Payer: Multiplan Commercial |
$1,197.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,422.15
|
| Rate for Payer: Quartz Beloit One Network |
$658.68
|
| Rate for Payer: Quartz Commercial |
$853.29
|
| Rate for Payer: The Alliance Commercial |
$748.50
|
| Rate for Payer: United Healthcare Medicaid |
$173.97
|
| Rate for Payer: WEA Trust Commercial |
$823.35
|
| Rate for Payer: WPS Commercial |
$477.24
|
|
|
FLUIDAIRE ELITE RENUS062
|
Facility
|
OP
|
$1,571.00
|
|
| Hospital Charge Code |
2964102
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$439.88 |
| Max. Negotiated Rate |
$6,284.00 |
| Rate for Payer: Aetna Commercial |
$1,413.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,351.06
|
| Rate for Payer: Aetna Managed Medicare |
$439.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,021.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$785.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$754.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$832.63
|
| Rate for Payer: Cash Price |
$471.30
|
| Rate for Payer: Cigna Commercial |
$1,445.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$879.13
|
| Rate for Payer: Health EOS Commercial |
$1,398.19
|
| Rate for Payer: HFN Commercial |
$1,445.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,178.25
|
| Rate for Payer: Multiplan Commercial |
$1,256.80
|
| Rate for Payer: NAPHCARE Commercial |
$942.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,445.32
|
| Rate for Payer: Quartz Beloit One Network |
$769.79
|
| Rate for Payer: Quartz Commercial |
$1,021.15
|
| Rate for Payer: Quartz Medicare Advantage |
$942.60
|
| Rate for Payer: The Alliance Commercial |
$6,284.00
|
| Rate for Payer: WEA Trust Commercial |
$864.05
|
| Rate for Payer: WPS Commercial |
$1,163.64
|
|
|
FLUIDAIRE ELITE RENUS062
|
Facility
|
IP
|
$1,571.00
|
|
| Hospital Charge Code |
2964102
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$769.79 |
| Max. Negotiated Rate |
$1,445.32 |
| Rate for Payer: Aetna Commercial |
$1,413.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,351.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$832.63
|
| Rate for Payer: Cash Price |
$471.30
|
| Rate for Payer: Cigna Commercial |
$1,445.32
|
| Rate for Payer: Health EOS Commercial |
$1,398.19
|
| Rate for Payer: HFN Commercial |
$1,445.32
|
| Rate for Payer: Multiplan Commercial |
$1,256.80
|
| Rate for Payer: NAPHCARE Commercial |
$942.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,445.32
|
| Rate for Payer: Quartz Beloit One Network |
$769.79
|
| Rate for Payer: Quartz Commercial |
$942.60
|
| Rate for Payer: WEA Trust Commercial |
$864.05
|
| Rate for Payer: WPS Commercial |
$1,163.64
|
|
|
FLUID PRESSURE, MUSCLE 20950
|
Professional
|
Both
|
$874.00
|
|
|
Service Code
|
CPT 20950
|
| Hospital Charge Code |
3013717
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$186.81 |
| Max. Negotiated Rate |
$830.30 |
| Rate for Payer: Aetna Commercial |
$830.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$751.64
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cigna Commercial |
$830.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$186.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$524.40
|
| Rate for Payer: Health EOS Commercial |
$795.34
|
| Rate for Payer: HFN Commercial |
$830.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$289.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$289.71
|
| Rate for Payer: Multiplan Commercial |
$699.20
|
| Rate for Payer: Preferred Network Access Commercial |
$830.30
|
| Rate for Payer: Quartz Beloit One Network |
$384.56
|
| Rate for Payer: Quartz Commercial |
$498.18
|
| Rate for Payer: The Alliance Commercial |
$437.00
|
| Rate for Payer: United Healthcare Medicaid |
$186.81
|
| Rate for Payer: WEA Trust Commercial |
$480.70
|
| Rate for Payer: WPS Commercial |
$647.37
|
|
|
Fluid Sheilds
|
Facility
|
IP
|
$1.00
|
|
| Hospital Charge Code |
3040308
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.60
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
Fluid Sheilds
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
3040308
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Aetna Managed Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.56
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.65
|
| Rate for Payer: Quartz Medicare Advantage |
$0.60
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
FLUID WARMER DISPOSABLE #24250
|
Facility
|
IP
|
$308.00
|
|
| Hospital Charge Code |
2963190
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$150.92 |
| Max. Negotiated Rate |
$283.36 |
| Rate for Payer: Aetna Commercial |
$277.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.24
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cigna Commercial |
$283.36
|
| Rate for Payer: Health EOS Commercial |
$274.12
|
| Rate for Payer: HFN Commercial |
$283.36
|
| Rate for Payer: Multiplan Commercial |
$246.40
|
| Rate for Payer: NAPHCARE Commercial |
$184.80
|
| Rate for Payer: Preferred Network Access Commercial |
$283.36
|
| Rate for Payer: Quartz Beloit One Network |
$150.92
|
| Rate for Payer: Quartz Commercial |
$184.80
|
| Rate for Payer: WEA Trust Commercial |
$169.40
|
| Rate for Payer: WPS Commercial |
$228.14
|
|
|
FLUID WARMER DISPOSABLE #24250
|
Facility
|
OP
|
$308.00
|
|
| Hospital Charge Code |
2963190
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.24 |
| Max. Negotiated Rate |
$1,232.00 |
| Rate for Payer: Aetna Commercial |
$277.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.88
|
| Rate for Payer: Aetna Managed Medicare |
$86.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$200.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$154.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.24
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cigna Commercial |
$283.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.36
|
| Rate for Payer: Health EOS Commercial |
$274.12
|
| Rate for Payer: HFN Commercial |
$283.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$231.00
|
| Rate for Payer: Multiplan Commercial |
$246.40
|
| Rate for Payer: NAPHCARE Commercial |
$184.80
|
| Rate for Payer: Preferred Network Access Commercial |
$283.36
|
| Rate for Payer: Quartz Beloit One Network |
$150.92
|
| Rate for Payer: Quartz Commercial |
$200.20
|
| Rate for Payer: Quartz Medicare Advantage |
$184.80
|
| Rate for Payer: The Alliance Commercial |
$1,232.00
|
| Rate for Payer: WEA Trust Commercial |
$169.40
|
| Rate for Payer: WPS Commercial |
$228.14
|
|
|
Flulaval QIV PF syr (0.5ml) 6mo & up (Dialysis) 90686
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
6219914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Aetna Managed Medicare |
$6.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.57
|
| Rate for Payer: Health EOS Commercial |
$21.36
|
| Rate for Payer: HFN Commercial |
$22.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: NAPHCARE Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22.08
|
| Rate for Payer: Quartz Beloit One Network |
$11.76
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: Quartz Medicare Advantage |
$14.40
|
| Rate for Payer: The Alliance Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$55.88
|
|
|
Flulaval QIV PF syr (0.5ml) 6mo & up (Dialysis) 90686
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
6219914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.08
|
| Rate for Payer: Health EOS Commercial |
$21.36
|
| Rate for Payer: HFN Commercial |
$22.08
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: NAPHCARE Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22.08
|
| Rate for Payer: Quartz Beloit One Network |
$11.76
|
| Rate for Payer: Quartz Commercial |
$14.40
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$17.78
|
|
|
Flulaval QIV PF syr (0.5ml) 6mo & up - Flu Virus, Inactivated Charge
|
Professional
|
Both
|
$24.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5845628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$55.88 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.35
|
| Rate for Payer: Health EOS Commercial |
$21.84
|
| Rate for Payer: HFN Commercial |
$22.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.59
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$22.80
|
| Rate for Payer: Quartz Beloit One Network |
$10.56
|
| Rate for Payer: Quartz Commercial |
$13.68
|
| Rate for Payer: The Alliance Commercial |
$12.00
|
| Rate for Payer: United Healthcare Medicaid |
$37.35
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$55.88
|
|
|
Flulaval QIV PF syr (0.5ml) 6mo & up - Flu Virus, Inactivated Charge
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5845628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Aetna Managed Medicare |
$6.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.57
|
| Rate for Payer: Health EOS Commercial |
$21.36
|
| Rate for Payer: HFN Commercial |
$22.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: NAPHCARE Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22.08
|
| Rate for Payer: Quartz Beloit One Network |
$11.76
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: Quartz Medicare Advantage |
$14.40
|
| Rate for Payer: The Alliance Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$55.88
|
|
|
Flulaval QIV PF syr (0.5ml) 6mo & up - Flu Virus, Inactivated Charge
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5845628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.08
|
| Rate for Payer: Health EOS Commercial |
$21.36
|
| Rate for Payer: HFN Commercial |
$22.08
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: NAPHCARE Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22.08
|
| Rate for Payer: Quartz Beloit One Network |
$11.76
|
| Rate for Payer: Quartz Commercial |
$14.40
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$17.78
|
|
|
Flulaval QIV PF syr (0.5ml) 6mo & up (Peritoneal) 90686
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
6219915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.08
|
| Rate for Payer: Health EOS Commercial |
$21.36
|
| Rate for Payer: HFN Commercial |
$22.08
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: NAPHCARE Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22.08
|
| Rate for Payer: Quartz Beloit One Network |
$11.76
|
| Rate for Payer: Quartz Commercial |
$14.40
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$17.78
|
|
|
Flulaval QIV PF syr (0.5ml) 6mo & up (Peritoneal) 90686
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
6219915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Aetna Managed Medicare |
$6.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.57
|
| Rate for Payer: Health EOS Commercial |
$21.36
|
| Rate for Payer: HFN Commercial |
$22.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: NAPHCARE Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22.08
|
| Rate for Payer: Quartz Beloit One Network |
$11.76
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: Quartz Medicare Advantage |
$14.40
|
| Rate for Payer: The Alliance Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$55.88
|
|
