|
Hib PRP-OMP 90647 VFC Charge
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90647
|
| Hospital Charge Code |
5586166
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE 90648 - VFC
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
5949632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$20.58 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.00
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: United Healthcare Medicaid |
$13.95
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE 90648 - VFC
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
5949632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE 90648 - VFC
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
5949632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
HIB Vaccine, PRP-T, IM 90648
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3455574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.95 |
| Max. Negotiated Rate |
$106.70 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$106.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.39
|
| Rate for Payer: Health EOS Commercial |
$102.21
|
| Rate for Payer: HFN Commercial |
$106.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: Preferred Network Access Commercial |
$106.70
|
| Rate for Payer: Quartz Beloit One Network |
$49.42
|
| Rate for Payer: Quartz Commercial |
$64.02
|
| Rate for Payer: The Alliance Commercial |
$56.16
|
| Rate for Payer: United Healthcare Medicaid |
$13.95
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
HIB Vaccine, PRP-T, IM 90648
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3455574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$103.33 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$67.39
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
HIB Vaccine, PRP-T, IM 90648
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3455574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.45 |
| Max. Negotiated Rate |
$103.33 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Aetna Managed Medicare |
$31.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.86
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$84.24
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$67.39
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$73.01
|
| Rate for Payer: Quartz Medicare Advantage |
$67.39
|
| Rate for Payer: The Alliance Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
High - Blood Glucose Hi/Lo
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3052356
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$48.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
High - Blood Glucose Hi/Lo
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3052356
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Aetna Managed Medicare |
$5.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.70
|
| Rate for Payer: Anthem Medicare Advantage |
$5.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.24
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.24
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: NAPHCARE Commercial |
$7.86
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$52.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5.24
|
| Rate for Payer: The Alliance Commercial |
$20.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.24
|
| Rate for Payer: United Healthcare PPO |
$60.06
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: Wellcare Medicare |
$5.24
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
High Concentration Mask - Ped.
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
3040338
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.87
|
| Rate for Payer: Health EOS Commercial |
$2.78
|
| Rate for Payer: HFN Commercial |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2.87
|
| Rate for Payer: Quartz Beloit One Network |
$1.53
|
| Rate for Payer: Quartz Commercial |
$1.87
|
| Rate for Payer: WEA Trust Commercial |
$1.72
|
| Rate for Payer: WPS Commercial |
$2.31
|
|
|
High Concentration Mask - Ped.
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
3040338
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.68
|
| Rate for Payer: Aetna Managed Medicare |
$0.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.75
|
| Rate for Payer: Health EOS Commercial |
$2.78
|
| Rate for Payer: HFN Commercial |
$2.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: NAPHCARE Commercial |
$1.87
|
| Rate for Payer: Preferred Network Access Commercial |
$2.87
|
| Rate for Payer: Quartz Beloit One Network |
$1.53
|
| Rate for Payer: Quartz Commercial |
$2.03
|
| Rate for Payer: Quartz Medicare Advantage |
$1.87
|
| Rate for Payer: The Alliance Commercial |
$1.56
|
| Rate for Payer: WEA Trust Commercial |
$1.72
|
| Rate for Payer: WPS Commercial |
$2.31
|
|
|
HIGH ENERGY ESWT, PLANTAR F 28890
|
Professional
|
Both
|
$2,261.00
|
|
|
Service Code
|
CPT 28890
|
| Hospital Charge Code |
3014287
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$203.35 |
| Max. Negotiated Rate |
$2,233.87 |
| Rate for Payer: Aetna Commercial |
$2,233.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,022.24
|
| Rate for Payer: Aetna Managed Medicare |
$203.35
|
| Rate for Payer: Anthem Medicare Advantage |
$203.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$203.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$203.35
|
| Rate for Payer: Cash Price |
$678.30
|
| Rate for Payer: Cash Price |
$678.30
|
| Rate for Payer: Cash Price |
$678.30
|
| Rate for Payer: Cigna Commercial |
$2,233.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$303.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.35
|
| Rate for Payer: Health EOS Commercial |
$2,139.81
|
| Rate for Payer: HFN Commercial |
$2,233.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$770.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$770.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$203.35
|
| Rate for Payer: Multiplan Commercial |
$1,881.15
|
| Rate for Payer: NAPHCARE Commercial |
$305.03
|
| Rate for Payer: Preferred Network Access Commercial |
$2,233.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,034.63
|
| Rate for Payer: Quartz Commercial |
$1,340.32
|
| Rate for Payer: Quartz Medicare Advantage |
$203.35
|
| Rate for Payer: The Alliance Commercial |
$864.24
|
| Rate for Payer: United Healthcare Medicaid |
$303.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$203.35
|
| Rate for Payer: WEA Trust Commercial |
$1,293.29
|
| Rate for Payer: WPS Commercial |
$915.08
|
|
|
H. influenzae Type B Antigen
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$62.19
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$48.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
H. influenzae Type B Antigen
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$57.41
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
H. influenzae Type B Antigen
|
Professional
|
Both
|
$92.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$90.90 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$90.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$87.07
|
| Rate for Payer: HFN Commercial |
$90.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$90.90
|
| Rate for Payer: Quartz Beloit One Network |
$42.10
|
| Rate for Payer: Quartz Commercial |
$54.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$52.81
|
|
|
HINGE BOLT M6 MEDIUM 4934-1-008
|
Facility
|
IP
|
$1,163.00
|
|
| Hospital Charge Code |
6001643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$592.66 |
| Max. Negotiated Rate |
$1,112.76 |
| Rate for Payer: Aetna Commercial |
$1,088.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,040.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$641.05
|
| Rate for Payer: Cash Price |
$348.90
|
| Rate for Payer: Cigna Commercial |
$1,112.76
|
| Rate for Payer: Health EOS Commercial |
$1,076.47
|
| Rate for Payer: HFN Commercial |
$1,112.76
|
| Rate for Payer: Multiplan Commercial |
$967.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,112.76
|
| Rate for Payer: Quartz Beloit One Network |
$592.66
|
| Rate for Payer: Quartz Commercial |
$725.71
|
| Rate for Payer: WEA Trust Commercial |
$665.24
|
| Rate for Payer: WPS Commercial |
$895.86
|
|
|
HINGE BOLT M6 MEDIUM 4934-1-008
|
Facility
|
OP
|
$1,163.00
|
|
| Hospital Charge Code |
6001643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$338.67 |
| Max. Negotiated Rate |
$1,112.76 |
| Rate for Payer: Aetna Commercial |
$1,088.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,040.19
|
| Rate for Payer: Aetna Managed Medicare |
$338.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$786.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$604.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$580.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$641.05
|
| Rate for Payer: Cash Price |
$348.90
|
| Rate for Payer: Cigna Commercial |
$1,112.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$676.87
|
| Rate for Payer: Health EOS Commercial |
$1,076.47
|
| Rate for Payer: HFN Commercial |
$1,112.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$907.14
|
| Rate for Payer: Multiplan Commercial |
$967.62
|
| Rate for Payer: NAPHCARE Commercial |
$725.71
|
| Rate for Payer: Preferred Network Access Commercial |
$1,112.76
|
| Rate for Payer: Quartz Beloit One Network |
$592.66
|
| Rate for Payer: Quartz Commercial |
$786.19
|
| Rate for Payer: Quartz Medicare Advantage |
$725.71
|
| Rate for Payer: The Alliance Commercial |
$604.76
|
| Rate for Payer: WEA Trust Commercial |
$665.24
|
| Rate for Payer: WPS Commercial |
$895.86
|
|
|
HINGE COUPLING HOFFMANN LIMB 4933-0-800
|
Facility
|
IP
|
$3,343.00
|
|
| Hospital Charge Code |
6065672
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,703.59 |
| Max. Negotiated Rate |
$3,198.58 |
| Rate for Payer: Aetna Commercial |
$3,129.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,989.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,842.66
|
| Rate for Payer: Cash Price |
$1,002.90
|
| Rate for Payer: Cigna Commercial |
$3,198.58
|
| Rate for Payer: Health EOS Commercial |
$3,094.28
|
| Rate for Payer: HFN Commercial |
$3,198.58
|
| Rate for Payer: Multiplan Commercial |
$2,781.38
|
| Rate for Payer: Preferred Network Access Commercial |
$3,198.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,703.59
|
| Rate for Payer: Quartz Commercial |
$2,086.03
|
| Rate for Payer: WEA Trust Commercial |
$1,912.20
|
| Rate for Payer: WPS Commercial |
$2,575.11
|
|
|
HINGE COUPLING HOFFMANN LIMB 4933-0-800
|
Facility
|
OP
|
$3,343.00
|
|
| Hospital Charge Code |
6065672
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$973.48 |
| Max. Negotiated Rate |
$3,198.58 |
| Rate for Payer: Aetna Commercial |
$3,129.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,989.98
|
| Rate for Payer: Aetna Managed Medicare |
$973.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,259.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,738.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,668.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,842.66
|
| Rate for Payer: Cash Price |
$1,002.90
|
| Rate for Payer: Cigna Commercial |
$3,198.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,945.63
|
| Rate for Payer: Health EOS Commercial |
$3,094.28
|
| Rate for Payer: HFN Commercial |
$3,198.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,607.54
|
| Rate for Payer: Multiplan Commercial |
$2,781.38
|
| Rate for Payer: NAPHCARE Commercial |
$2,086.03
|
| Rate for Payer: Preferred Network Access Commercial |
$3,198.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,703.59
|
| Rate for Payer: Quartz Commercial |
$2,259.87
|
| Rate for Payer: Quartz Medicare Advantage |
$2,086.03
|
| Rate for Payer: The Alliance Commercial |
$1,738.36
|
| Rate for Payer: WEA Trust Commercial |
$1,912.20
|
| Rate for Payer: WPS Commercial |
$2,575.11
|
|
|
HINGE COUPLING UNIVERSAL HOFFMANN LIMB 4933-0-700
|
Facility
|
OP
|
$3,335.00
|
|
| Hospital Charge Code |
6190959
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$971.15 |
| Max. Negotiated Rate |
$3,190.93 |
| Rate for Payer: Aetna Commercial |
$3,121.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,982.82
|
| Rate for Payer: Aetna Managed Medicare |
$971.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,254.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,734.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,664.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,838.25
|
| Rate for Payer: Cash Price |
$1,000.50
|
| Rate for Payer: Cigna Commercial |
$3,190.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,940.97
|
| Rate for Payer: Health EOS Commercial |
$3,086.88
|
| Rate for Payer: HFN Commercial |
$3,190.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,601.30
|
| Rate for Payer: Multiplan Commercial |
$2,774.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,081.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,190.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,699.52
|
| Rate for Payer: Quartz Commercial |
$2,254.46
|
| Rate for Payer: Quartz Medicare Advantage |
$2,081.04
|
| Rate for Payer: The Alliance Commercial |
$1,734.20
|
| Rate for Payer: WEA Trust Commercial |
$1,907.62
|
| Rate for Payer: WPS Commercial |
$2,568.95
|
|
|
HINGE COUPLING UNIVERSAL HOFFMANN LIMB 4933-0-700
|
Facility
|
IP
|
$3,335.00
|
|
| Hospital Charge Code |
6190959
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,699.52 |
| Max. Negotiated Rate |
$3,190.93 |
| Rate for Payer: Aetna Commercial |
$3,121.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,982.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,838.25
|
| Rate for Payer: Cash Price |
$1,000.50
|
| Rate for Payer: Cigna Commercial |
$3,190.93
|
| Rate for Payer: Health EOS Commercial |
$3,086.88
|
| Rate for Payer: HFN Commercial |
$3,190.93
|
| Rate for Payer: Multiplan Commercial |
$2,774.72
|
| Rate for Payer: Preferred Network Access Commercial |
$3,190.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,699.52
|
| Rate for Payer: Quartz Commercial |
$2,081.04
|
| Rate for Payer: WEA Trust Commercial |
$1,907.62
|
| Rate for Payer: WPS Commercial |
$2,568.95
|
|
|
Hinged knee brace - PT Equipment Issued Rehab
|
Facility
|
IP
|
$1,047.00
|
|
|
Service Code
|
HCPCS L1831
|
| Hospital Charge Code |
2989875
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$533.55 |
| Max. Negotiated Rate |
$1,001.77 |
| Rate for Payer: Aetna Commercial |
$979.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$936.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$577.11
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$1,001.77
|
| Rate for Payer: Health EOS Commercial |
$969.10
|
| Rate for Payer: HFN Commercial |
$1,001.77
|
| Rate for Payer: Multiplan Commercial |
$871.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,001.77
|
| Rate for Payer: Quartz Beloit One Network |
$533.55
|
| Rate for Payer: Quartz Commercial |
$653.33
|
| Rate for Payer: WEA Trust Commercial |
$598.88
|
| Rate for Payer: WPS Commercial |
$806.50
|
|
|
Hinged knee brace - PT Equipment Issued Rehab
|
Facility
|
OP
|
$1,047.00
|
|
|
Service Code
|
HCPCS L1831
|
| Hospital Charge Code |
2989875
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$110.29 |
| Max. Negotiated Rate |
$1,504.67 |
| Rate for Payer: Aetna Commercial |
$979.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$936.44
|
| Rate for Payer: Aetna Managed Medicare |
$304.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.29
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$110.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$577.11
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$1,001.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$609.35
|
| Rate for Payer: Health EOS Commercial |
$969.10
|
| Rate for Payer: HFN Commercial |
$1,001.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$816.66
|
| Rate for Payer: Multiplan Commercial |
$871.10
|
| Rate for Payer: NAPHCARE Commercial |
$653.33
|
| Rate for Payer: Preferred Network Access Commercial |
$1,001.77
|
| Rate for Payer: Quartz Beloit One Network |
$533.55
|
| Rate for Payer: Quartz Commercial |
$707.77
|
| Rate for Payer: Quartz Medicare Advantage |
$653.33
|
| Rate for Payer: The Alliance Commercial |
$1,504.67
|
| Rate for Payer: WEA Trust Commercial |
$598.88
|
| Rate for Payer: WPS Commercial |
$806.50
|
|
|
Hinged knee brace - PT Equipment Issued Rehab
|
Professional
|
Both
|
$1,047.00
|
|
|
Service Code
|
HCPCS L1831
|
| Hospital Charge Code |
2989875
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$376.17 |
| Max. Negotiated Rate |
$1,084.62 |
| Rate for Payer: Aetna Commercial |
$1,034.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$936.44
|
| Rate for Payer: Aetna Managed Medicare |
$376.17
|
| Rate for Payer: Anthem Medicare Advantage |
$376.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$376.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$376.17
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$1,034.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$544.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$376.17
|
| Rate for Payer: Health EOS Commercial |
$990.88
|
| Rate for Payer: HFN Commercial |
$1,034.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,084.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,084.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$376.17
|
| Rate for Payer: Multiplan Commercial |
$871.10
|
| Rate for Payer: NAPHCARE Commercial |
$564.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,034.44
|
| Rate for Payer: Quartz Beloit One Network |
$479.11
|
| Rate for Payer: Quartz Commercial |
$620.66
|
| Rate for Payer: Quartz Medicare Advantage |
$376.17
|
| Rate for Payer: The Alliance Commercial |
$1,034.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$376.17
|
| Rate for Payer: WEA Trust Commercial |
$598.88
|
| Rate for Payer: WPS Commercial |
$658.29
|
|
|
Hip Abduction Brace - PT Equipment Issued Rehab
|
Professional
|
Both
|
$3,663.00
|
|
|
Service Code
|
HCPCS L1686
|
| Hospital Charge Code |
2989874
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,197.62 |
| Max. Negotiated Rate |
$3,619.04 |
| Rate for Payer: Aetna Commercial |
$3,619.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,276.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,197.62
|
| Rate for Payer: Anthem Medicare Advantage |
$1,197.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,197.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,197.62
|
| Rate for Payer: Cash Price |
$1,098.90
|
| Rate for Payer: Cash Price |
$1,098.90
|
| Rate for Payer: Cigna Commercial |
$3,619.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,904.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,197.62
|
| Rate for Payer: Health EOS Commercial |
$3,466.66
|
| Rate for Payer: HFN Commercial |
$3,619.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,453.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,453.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,197.62
|
| Rate for Payer: Multiplan Commercial |
$3,047.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,796.43
|
| Rate for Payer: Preferred Network Access Commercial |
$3,619.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,676.19
|
| Rate for Payer: Quartz Commercial |
$2,171.43
|
| Rate for Payer: Quartz Medicare Advantage |
$1,197.62
|
| Rate for Payer: The Alliance Commercial |
$3,293.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,197.62
|
| Rate for Payer: WEA Trust Commercial |
$2,095.24
|
| Rate for Payer: WPS Commercial |
$2,095.84
|
|
