|
Hib PRP-OMP 90647 VFC Charge
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90647
|
| Hospital Charge Code |
5586166
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
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 |
$9.17 |
| Max. Negotiated Rate |
$45.80 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.04
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$45.80
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
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 |
$5.83 |
| Max. Negotiated Rate |
$83.32 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
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 |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
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 |
$52.92 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$64.80
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
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 |
$19.04 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$102.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.80
|
| Rate for Payer: Health EOS Commercial |
$98.28
|
| Rate for Payer: HFN Commercial |
$102.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.04
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Preferred Network Access Commercial |
$102.60
|
| Rate for Payer: Quartz Beloit One Network |
$47.52
|
| Rate for Payer: Quartz Commercial |
$61.56
|
| Rate for Payer: The Alliance Commercial |
$54.00
|
| Rate for Payer: United Healthcare Medicaid |
$45.80
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
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 |
$30.24 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Aetna Managed Medicare |
$30.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.44
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.00
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$70.20
|
| Rate for Payer: Quartz Medicare Advantage |
$64.80
|
| Rate for Payer: The Alliance Commercial |
$432.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
High - Blood Glucose Hi/Lo
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3052356
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.73 |
| Max. Negotiated Rate |
$70.84 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.81
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$70.84
|
| Rate for Payer: Health EOS Commercial |
$68.53
|
| Rate for Payer: HFN Commercial |
$70.84
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: NAPHCARE Commercial |
$46.20
|
| Rate for Payer: Preferred Network Access Commercial |
$70.84
|
| Rate for Payer: Quartz Beloit One Network |
$37.73
|
| Rate for Payer: Quartz Commercial |
$46.20
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
High - Blood Glucose Hi/Lo
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3052356
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$70.84 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Aetna Managed Medicare |
$5.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.37
|
| Rate for Payer: Anthem Medicaid |
$4.45
|
| Rate for Payer: Anthem Medicare Advantage |
$5.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.04
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$70.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.09
|
| Rate for Payer: Dean Health Medicaid |
$4.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.04
|
| Rate for Payer: Health EOS Commercial |
$68.53
|
| Rate for Payer: HFN Commercial |
$70.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.04
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.04
|
| Rate for Payer: Managed Health Services Medicaid |
$4.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.04
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.56
|
| Rate for Payer: Preferred Network Access Commercial |
$70.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.45
|
| Rate for Payer: Quartz Beloit One Network |
$37.73
|
| Rate for Payer: Quartz Commercial |
$50.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5.04
|
| Rate for Payer: The Alliance Commercial |
$20.16
|
| Rate for Payer: United Healthcare Medicaid |
$4.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.04
|
| Rate for Payer: United Healthcare PPO |
$57.75
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: Wellcare Medicare |
$5.04
|
| Rate for Payer: WMAP Medicaid |
$4.45
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
High Concentration Mask - Ped.
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
3040338
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
High Concentration Mask - Ped.
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
3040338
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.68
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1.80
|
| Rate for Payer: The Alliance Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
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 |
$292.15 |
| Max. Negotiated Rate |
$2,147.95 |
| Rate for Payer: Aetna Commercial |
$2,147.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,944.46
|
| 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 |
$2,147.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$292.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,356.60
|
| Rate for Payer: Health EOS Commercial |
$2,057.51
|
| Rate for Payer: HFN Commercial |
$2,147.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$741.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$741.09
|
| Rate for Payer: Multiplan Commercial |
$1,808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,147.95
|
| Rate for Payer: Quartz Beloit One Network |
$994.84
|
| Rate for Payer: Quartz Commercial |
$1,288.77
|
| Rate for Payer: The Alliance Commercial |
$1,130.50
|
| Rate for Payer: United Healthcare Medicaid |
$292.15
|
| Rate for Payer: WEA Trust Commercial |
$1,243.55
|
| Rate for Payer: WPS Commercial |
$1,674.72
|
|
|
H. influenzae Type B Antigen
|
Professional
|
Both
|
$92.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.48 |
| Max. Negotiated Rate |
$87.40 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$87.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.20
|
| Rate for Payer: Health EOS Commercial |
$83.72
|
| Rate for Payer: HFN Commercial |
$87.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.74
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: Preferred Network Access Commercial |
$87.40
|
| Rate for Payer: Quartz Beloit One Network |
$40.48
|
| Rate for Payer: Quartz Commercial |
$52.44
|
| Rate for Payer: The Alliance Commercial |
$46.00
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
H. influenzae Type B Antigen
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Aetna Managed Medicare |
$11.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.16
|
| Rate for Payer: Anthem Medicaid |
$11.92
|
| Rate for Payer: Anthem Medicare Advantage |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.54
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.48
|
| Rate for Payer: Dean Health Medicaid |
$11.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.54
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.54
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.54
|
| Rate for Payer: Managed Health Services Medicaid |
$12.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.54
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$17.31
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.92
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$59.80
|
| Rate for Payer: Quartz Medicare Advantage |
$11.54
|
| Rate for Payer: The Alliance Commercial |
$46.16
|
| Rate for Payer: United Healthcare Medicaid |
$11.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.54
|
| Rate for Payer: United Healthcare PPO |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: Wellcare Medicare |
$11.54
|
| Rate for Payer: WMAP Medicaid |
$11.92
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
H. influenzae Type B Antigen
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096644
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$55.20
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
HINGE BOLT M6 MEDIUM 4934-1-008
|
Facility
|
OP
|
$1,163.00
|
|
| Hospital Charge Code |
6001643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$325.64 |
| Max. Negotiated Rate |
$4,652.00 |
| Rate for Payer: Aetna Commercial |
$1,046.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,000.18
|
| Rate for Payer: Aetna Managed Medicare |
$325.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$755.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$581.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$558.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.39
|
| Rate for Payer: Cash Price |
$348.90
|
| Rate for Payer: Cigna Commercial |
$1,069.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$650.81
|
| Rate for Payer: Health EOS Commercial |
$1,035.07
|
| Rate for Payer: HFN Commercial |
$1,069.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$872.25
|
| Rate for Payer: Multiplan Commercial |
$930.40
|
| Rate for Payer: NAPHCARE Commercial |
$697.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,069.96
|
| Rate for Payer: Quartz Beloit One Network |
$569.87
|
| Rate for Payer: Quartz Commercial |
$755.95
|
| Rate for Payer: Quartz Medicare Advantage |
$697.80
|
| Rate for Payer: The Alliance Commercial |
$4,652.00
|
| Rate for Payer: WEA Trust Commercial |
$639.65
|
| Rate for Payer: WPS Commercial |
$861.43
|
|
|
HINGE BOLT M6 MEDIUM 4934-1-008
|
Facility
|
IP
|
$1,163.00
|
|
| Hospital Charge Code |
6001643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$569.87 |
| Max. Negotiated Rate |
$1,069.96 |
| Rate for Payer: Aetna Commercial |
$1,046.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,000.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.39
|
| Rate for Payer: Cash Price |
$348.90
|
| Rate for Payer: Cigna Commercial |
$1,069.96
|
| Rate for Payer: Health EOS Commercial |
$1,035.07
|
| Rate for Payer: HFN Commercial |
$1,069.96
|
| Rate for Payer: Multiplan Commercial |
$930.40
|
| Rate for Payer: NAPHCARE Commercial |
$697.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,069.96
|
| Rate for Payer: Quartz Beloit One Network |
$569.87
|
| Rate for Payer: Quartz Commercial |
$697.80
|
| Rate for Payer: WEA Trust Commercial |
$639.65
|
| Rate for Payer: WPS Commercial |
$861.43
|
|
|
HINGE COUPLING HOFFMANN LIMB 4933-0-800
|
Facility
|
IP
|
$3,343.00
|
|
| Hospital Charge Code |
6065672
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,638.07 |
| Max. Negotiated Rate |
$3,075.56 |
| Rate for Payer: Aetna Commercial |
$3,008.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,874.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,771.79
|
| Rate for Payer: Cash Price |
$1,002.90
|
| Rate for Payer: Cigna Commercial |
$3,075.56
|
| Rate for Payer: Health EOS Commercial |
$2,975.27
|
| Rate for Payer: HFN Commercial |
$3,075.56
|
| Rate for Payer: Multiplan Commercial |
$2,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,005.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,075.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,638.07
|
| Rate for Payer: Quartz Commercial |
$2,005.80
|
| Rate for Payer: WEA Trust Commercial |
$1,838.65
|
| Rate for Payer: WPS Commercial |
$2,476.16
|
|
|
HINGE COUPLING HOFFMANN LIMB 4933-0-800
|
Facility
|
OP
|
$3,343.00
|
|
| Hospital Charge Code |
6065672
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$936.04 |
| Max. Negotiated Rate |
$13,372.00 |
| Rate for Payer: Aetna Commercial |
$3,008.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,874.98
|
| Rate for Payer: Aetna Managed Medicare |
$936.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,172.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,671.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,604.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,771.79
|
| Rate for Payer: Cash Price |
$1,002.90
|
| Rate for Payer: Cigna Commercial |
$3,075.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,870.74
|
| Rate for Payer: Health EOS Commercial |
$2,975.27
|
| Rate for Payer: HFN Commercial |
$3,075.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,507.25
|
| Rate for Payer: Multiplan Commercial |
$2,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,005.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,075.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,638.07
|
| Rate for Payer: Quartz Commercial |
$2,172.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,005.80
|
| Rate for Payer: The Alliance Commercial |
$13,372.00
|
| Rate for Payer: WEA Trust Commercial |
$1,838.65
|
| Rate for Payer: WPS Commercial |
$2,476.16
|
|
|
HINGE COUPLING UNIVERSAL HOFFMANN LIMB 4933-0-700
|
Facility
|
OP
|
$3,335.00
|
|
| Hospital Charge Code |
6190959
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$933.80 |
| Max. Negotiated Rate |
$13,340.00 |
| Rate for Payer: Aetna Commercial |
$3,001.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,868.10
|
| Rate for Payer: Aetna Managed Medicare |
$933.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,167.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,667.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,600.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,767.55
|
| Rate for Payer: Cash Price |
$1,000.50
|
| Rate for Payer: Cigna Commercial |
$3,068.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,866.27
|
| Rate for Payer: Health EOS Commercial |
$2,968.15
|
| Rate for Payer: HFN Commercial |
$3,068.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,501.25
|
| Rate for Payer: Multiplan Commercial |
$2,668.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,001.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,068.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,634.15
|
| Rate for Payer: Quartz Commercial |
$2,167.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,001.00
|
| Rate for Payer: The Alliance Commercial |
$13,340.00
|
| Rate for Payer: WEA Trust Commercial |
$1,834.25
|
| Rate for Payer: WPS Commercial |
$2,470.23
|
|
|
HINGE COUPLING UNIVERSAL HOFFMANN LIMB 4933-0-700
|
Facility
|
IP
|
$3,335.00
|
|
| Hospital Charge Code |
6190959
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,634.15 |
| Max. Negotiated Rate |
$3,068.20 |
| Rate for Payer: Aetna Commercial |
$3,001.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,868.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,767.55
|
| Rate for Payer: Cash Price |
$1,000.50
|
| Rate for Payer: Cigna Commercial |
$3,068.20
|
| Rate for Payer: Health EOS Commercial |
$2,968.15
|
| Rate for Payer: HFN Commercial |
$3,068.20
|
| Rate for Payer: Multiplan Commercial |
$2,668.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,001.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,068.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,634.15
|
| Rate for Payer: Quartz Commercial |
$2,001.00
|
| Rate for Payer: WEA Trust Commercial |
$1,834.25
|
| Rate for Payer: WPS Commercial |
$2,470.23
|
|
|
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 |
$513.03 |
| Max. Negotiated Rate |
$963.24 |
| Rate for Payer: Aetna Commercial |
$942.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.91
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$963.24
|
| Rate for Payer: Health EOS Commercial |
$931.83
|
| Rate for Payer: HFN Commercial |
$963.24
|
| Rate for Payer: Multiplan Commercial |
$837.60
|
| Rate for Payer: NAPHCARE Commercial |
$628.20
|
| Rate for Payer: Preferred Network Access Commercial |
$963.24
|
| Rate for Payer: Quartz Beloit One Network |
$513.03
|
| Rate for Payer: Quartz Commercial |
$628.20
|
| Rate for Payer: WEA Trust Commercial |
$575.85
|
| Rate for Payer: WPS Commercial |
$775.51
|
|
|
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 |
$106.05 |
| Max. Negotiated Rate |
$4,188.00 |
| Rate for Payer: Aetna Commercial |
$942.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.42
|
| Rate for Payer: Aetna Managed Medicare |
$293.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.91
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$963.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.90
|
| Rate for Payer: Health EOS Commercial |
$931.83
|
| Rate for Payer: HFN Commercial |
$963.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$785.25
|
| Rate for Payer: Multiplan Commercial |
$837.60
|
| Rate for Payer: NAPHCARE Commercial |
$628.20
|
| Rate for Payer: Preferred Network Access Commercial |
$963.24
|
| Rate for Payer: Quartz Beloit One Network |
$513.03
|
| Rate for Payer: Quartz Commercial |
$680.55
|
| Rate for Payer: Quartz Medicare Advantage |
$628.20
|
| Rate for Payer: The Alliance Commercial |
$4,188.00
|
| Rate for Payer: WEA Trust Commercial |
$575.85
|
| Rate for Payer: WPS Commercial |
$775.51
|
|
|
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 |
$460.68 |
| Max. Negotiated Rate |
$1,042.90 |
| Rate for Payer: Aetna Commercial |
$994.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.42
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$994.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$523.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$628.20
|
| Rate for Payer: Health EOS Commercial |
$952.77
|
| Rate for Payer: HFN Commercial |
$994.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,042.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,042.90
|
| Rate for Payer: Multiplan Commercial |
$837.60
|
| Rate for Payer: Preferred Network Access Commercial |
$994.65
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$596.79
|
| Rate for Payer: The Alliance Commercial |
$523.50
|
| Rate for Payer: WEA Trust Commercial |
$575.85
|
| Rate for Payer: WPS Commercial |
$775.51
|
|
|
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 |
$1,611.72 |
| Max. Negotiated Rate |
$3,479.85 |
| Rate for Payer: Aetna Commercial |
$3,479.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,150.18
|
| Rate for Payer: Cash Price |
$1,098.90
|
| Rate for Payer: Cash Price |
$1,098.90
|
| Rate for Payer: Cigna Commercial |
$3,479.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,831.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,197.80
|
| Rate for Payer: Health EOS Commercial |
$3,333.33
|
| Rate for Payer: HFN Commercial |
$3,479.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,320.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,320.32
|
| Rate for Payer: Multiplan Commercial |
$2,930.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,479.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,611.72
|
| Rate for Payer: Quartz Commercial |
$2,087.91
|
| Rate for Payer: The Alliance Commercial |
$1,831.50
|
| Rate for Payer: WEA Trust Commercial |
$2,014.65
|
| Rate for Payer: WPS Commercial |
$2,713.18
|
|
