|
Homovanillic Acid, Random Urine
|
Facility
|
IP
|
$46.59
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
4076076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.83 |
| Max. Negotiated Rate |
$42.86 |
| Rate for Payer: Aetna Commercial |
$41.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.69
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cigna Commercial |
$42.86
|
| Rate for Payer: Health EOS Commercial |
$41.47
|
| Rate for Payer: HFN Commercial |
$42.86
|
| Rate for Payer: Multiplan Commercial |
$37.27
|
| Rate for Payer: NAPHCARE Commercial |
$27.95
|
| Rate for Payer: Preferred Network Access Commercial |
$42.86
|
| Rate for Payer: Quartz Beloit One Network |
$22.83
|
| Rate for Payer: Quartz Commercial |
$27.95
|
| Rate for Payer: WEA Trust Commercial |
$25.62
|
| Rate for Payer: WPS Commercial |
$34.51
|
|
|
HOOK BLUNT 5MM 3316-8G
|
Facility
|
OP
|
$171.00
|
|
| Hospital Charge Code |
2964998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.88 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Aetna Managed Medicare |
$47.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.69
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.25
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$111.15
|
| Rate for Payer: Quartz Medicare Advantage |
$102.60
|
| Rate for Payer: The Alliance Commercial |
$684.00
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
HOOK BLUNT 5MM 3316-8G
|
Facility
|
IP
|
$171.00
|
|
| Hospital Charge Code |
2964998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.79 |
| Max. Negotiated Rate |
$157.32 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$102.60
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
HOOK SELF ADHESIVE VELCRO 1 25yd #7011-02-25"
|
Facility
|
IP
|
$50.00
|
|
| Hospital Charge Code |
2971376
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$46.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$46.00
|
| Rate for Payer: Health EOS Commercial |
$44.50
|
| Rate for Payer: HFN Commercial |
$46.00
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.00
|
| Rate for Payer: Preferred Network Access Commercial |
$46.00
|
| Rate for Payer: Quartz Beloit One Network |
$24.50
|
| Rate for Payer: Quartz Commercial |
$30.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
HOOK SELF ADHESIVE VELCRO 1 25yd #7011-02-25"
|
Facility
|
OP
|
$50.00
|
|
| Hospital Charge Code |
2971376
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Aetna Managed Medicare |
$14.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$46.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.98
|
| Rate for Payer: Health EOS Commercial |
$44.50
|
| Rate for Payer: HFN Commercial |
$46.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.00
|
| Rate for Payer: Preferred Network Access Commercial |
$46.00
|
| Rate for Payer: Quartz Beloit One Network |
$24.50
|
| Rate for Payer: Quartz Commercial |
$32.50
|
| Rate for Payer: Quartz Medicare Advantage |
$30.00
|
| Rate for Payer: The Alliance Commercial |
$200.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
HOOK SHARP 5MM 3311-8G
|
Facility
|
IP
|
$178.00
|
|
| Hospital Charge Code |
2964997
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$87.22 |
| Max. Negotiated Rate |
$163.76 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$106.80
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$106.80
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
HOOK SHARP 5MM 3311-8G
|
Facility
|
OP
|
$178.00
|
|
| Hospital Charge Code |
2964997
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.84 |
| Max. Negotiated Rate |
$712.00 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Aetna Managed Medicare |
$49.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$89.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.61
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.50
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$106.80
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$115.70
|
| Rate for Payer: Quartz Medicare Advantage |
$106.80
|
| Rate for Payer: The Alliance Commercial |
$712.00
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
HOOK-UP DSD SCOPES HI-DEF #HU0068
|
Facility
|
IP
|
$4,978.00
|
|
| Hospital Charge Code |
2973556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,439.22 |
| Max. Negotiated Rate |
$4,579.76 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$2,986.80
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
HOOK-UP DSD SCOPES HI-DEF #HU0068
|
Facility
|
OP
|
$4,978.00
|
|
| Hospital Charge Code |
2973556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,393.84 |
| Max. Negotiated Rate |
$19,912.00 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,235.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,785.69
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.50
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$3,235.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,986.80
|
| Rate for Payer: The Alliance Commercial |
$19,912.00
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
HOOKUP FOR DSD-201 HU0069
|
Facility
|
IP
|
$5,139.00
|
|
| Hospital Charge Code |
2973566
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,518.11 |
| Max. Negotiated Rate |
$4,727.88 |
| Rate for Payer: Aetna Commercial |
$4,625.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,419.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,723.67
|
| Rate for Payer: Cash Price |
$1,541.70
|
| Rate for Payer: Cigna Commercial |
$4,727.88
|
| Rate for Payer: Health EOS Commercial |
$4,573.71
|
| Rate for Payer: HFN Commercial |
$4,727.88
|
| Rate for Payer: Multiplan Commercial |
$4,111.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,083.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,727.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,518.11
|
| Rate for Payer: Quartz Commercial |
$3,083.40
|
| Rate for Payer: WEA Trust Commercial |
$2,826.45
|
| Rate for Payer: WPS Commercial |
$3,806.46
|
|
|
HOOKUP FOR DSD-201 HU0069
|
Facility
|
OP
|
$5,139.00
|
|
| Hospital Charge Code |
2973566
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,438.92 |
| Max. Negotiated Rate |
$20,556.00 |
| Rate for Payer: Aetna Commercial |
$4,625.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,419.54
|
| Rate for Payer: Aetna Managed Medicare |
$1,438.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,340.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,569.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,466.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,723.67
|
| Rate for Payer: Cash Price |
$1,541.70
|
| Rate for Payer: Cigna Commercial |
$4,727.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,875.78
|
| Rate for Payer: Health EOS Commercial |
$4,573.71
|
| Rate for Payer: HFN Commercial |
$4,727.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,854.25
|
| Rate for Payer: Multiplan Commercial |
$4,111.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,083.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,727.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,518.11
|
| Rate for Payer: Quartz Commercial |
$3,340.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,083.40
|
| Rate for Payer: The Alliance Commercial |
$20,556.00
|
| Rate for Payer: WEA Trust Commercial |
$2,826.45
|
| Rate for Payer: WPS Commercial |
$3,806.46
|
|
|
H Papilloma Vacc 3 dose im 90649
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
3373605
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$259.21 |
| Max. Negotiated Rate |
$486.68 |
| Rate for Payer: Aetna Commercial |
$476.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.37
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$486.68
|
| Rate for Payer: Health EOS Commercial |
$470.81
|
| Rate for Payer: HFN Commercial |
$486.68
|
| Rate for Payer: Multiplan Commercial |
$423.20
|
| Rate for Payer: NAPHCARE Commercial |
$317.40
|
| Rate for Payer: Preferred Network Access Commercial |
$486.68
|
| Rate for Payer: Quartz Beloit One Network |
$259.21
|
| Rate for Payer: Quartz Commercial |
$317.40
|
| Rate for Payer: WEA Trust Commercial |
$290.95
|
| Rate for Payer: WPS Commercial |
$391.83
|
|
|
H Papilloma Vacc 3 dose im 90649
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
3373605
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$148.12 |
| Max. Negotiated Rate |
$2,116.00 |
| Rate for Payer: Aetna Commercial |
$476.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.94
|
| Rate for Payer: Aetna Managed Medicare |
$148.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$343.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$264.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$253.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.37
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$486.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$296.03
|
| Rate for Payer: Health EOS Commercial |
$470.81
|
| Rate for Payer: HFN Commercial |
$486.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$396.75
|
| Rate for Payer: Multiplan Commercial |
$423.20
|
| Rate for Payer: NAPHCARE Commercial |
$317.40
|
| Rate for Payer: Preferred Network Access Commercial |
$486.68
|
| Rate for Payer: Quartz Beloit One Network |
$259.21
|
| Rate for Payer: Quartz Commercial |
$343.85
|
| Rate for Payer: Quartz Medicare Advantage |
$317.40
|
| Rate for Payer: The Alliance Commercial |
$2,116.00
|
| Rate for Payer: WEA Trust Commercial |
$290.95
|
| Rate for Payer: WPS Commercial |
$391.83
|
|
|
H Papilloma Vacc 3 dose im 90649
|
Professional
|
Both
|
$529.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
3373605
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$502.55 |
| Rate for Payer: Aetna Commercial |
$502.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.94
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$502.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$317.40
|
| Rate for Payer: Health EOS Commercial |
$481.39
|
| Rate for Payer: HFN Commercial |
$502.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$266.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$266.38
|
| Rate for Payer: Multiplan Commercial |
$423.20
|
| Rate for Payer: Preferred Network Access Commercial |
$502.55
|
| Rate for Payer: Quartz Beloit One Network |
$232.76
|
| Rate for Payer: Quartz Commercial |
$301.53
|
| Rate for Payer: The Alliance Commercial |
$264.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$290.95
|
| Rate for Payer: WPS Commercial |
$391.83
|
|
|
H Papilloma Vacc 3 dose im 90649VFC
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
5096653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$266.38 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$266.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$266.38
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
H Papilloma Vacc 3 dose im 90649VFC
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
5096653
|
|
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
|
|
|
H Papilloma Vacc 3 dose im 90649VFC
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
5096653
|
|
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
|
|
|
H-PLATE EXTENDED 1.3MM LEFT 221.321
|
Facility
|
OP
|
$3,334.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508592
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.52 |
| Max. Negotiated Rate |
$13,336.00 |
| Rate for Payer: Aetna Commercial |
$3,000.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,867.24
|
| Rate for Payer: Aetna Managed Medicare |
$933.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,167.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,667.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,600.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,767.02
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cigna Commercial |
$3,067.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,865.71
|
| Rate for Payer: Health EOS Commercial |
$2,967.26
|
| Rate for Payer: HFN Commercial |
$3,067.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,500.50
|
| Rate for Payer: Multiplan Commercial |
$2,667.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,000.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,067.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,633.66
|
| Rate for Payer: Quartz Commercial |
$2,167.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,000.40
|
| Rate for Payer: The Alliance Commercial |
$13,336.00
|
| Rate for Payer: WEA Trust Commercial |
$1,833.70
|
| Rate for Payer: WPS Commercial |
$2,469.49
|
|
|
H-PLATE EXTENDED 1.3MM LEFT 221.321
|
Facility
|
IP
|
$3,334.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508592
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,633.66 |
| Max. Negotiated Rate |
$3,067.28 |
| Rate for Payer: Aetna Commercial |
$3,000.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,867.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,767.02
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cigna Commercial |
$3,067.28
|
| Rate for Payer: Health EOS Commercial |
$2,967.26
|
| Rate for Payer: HFN Commercial |
$3,067.28
|
| Rate for Payer: Multiplan Commercial |
$2,667.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,000.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,067.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,633.66
|
| Rate for Payer: Quartz Commercial |
$2,000.40
|
| Rate for Payer: WEA Trust Commercial |
$1,833.70
|
| Rate for Payer: WPS Commercial |
$2,469.49
|
|
|
H-PLATE EXTENDED 1.3MM RIGHT 221.320
|
Facility
|
OP
|
$3,334.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.52 |
| Max. Negotiated Rate |
$13,336.00 |
| Rate for Payer: Aetna Commercial |
$3,000.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,867.24
|
| Rate for Payer: Aetna Managed Medicare |
$933.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,167.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,667.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,600.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,767.02
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cigna Commercial |
$3,067.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,865.71
|
| Rate for Payer: Health EOS Commercial |
$2,967.26
|
| Rate for Payer: HFN Commercial |
$3,067.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,500.50
|
| Rate for Payer: Multiplan Commercial |
$2,667.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,000.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,067.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,633.66
|
| Rate for Payer: Quartz Commercial |
$2,167.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,000.40
|
| Rate for Payer: The Alliance Commercial |
$13,336.00
|
| Rate for Payer: WEA Trust Commercial |
$1,833.70
|
| Rate for Payer: WPS Commercial |
$2,469.49
|
|
|
H-PLATE EXTENDED 1.3MM RIGHT 221.320
|
Facility
|
IP
|
$3,334.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,633.66 |
| Max. Negotiated Rate |
$3,067.28 |
| Rate for Payer: Aetna Commercial |
$3,000.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,867.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,767.02
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cigna Commercial |
$3,067.28
|
| Rate for Payer: Health EOS Commercial |
$2,967.26
|
| Rate for Payer: HFN Commercial |
$3,067.28
|
| Rate for Payer: Multiplan Commercial |
$2,667.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,000.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,067.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,633.66
|
| Rate for Payer: Quartz Commercial |
$2,000.40
|
| Rate for Payer: WEA Trust Commercial |
$1,833.70
|
| Rate for Payer: WPS Commercial |
$2,469.49
|
|
|
H-PLATE MATRIX MIDFACE 11HL TI 04.503.352
|
Facility
|
OP
|
$22,304.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349487
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,245.12 |
| Max. Negotiated Rate |
$89,216.00 |
| Rate for Payer: Aetna Commercial |
$20,073.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,181.44
|
| Rate for Payer: Aetna Managed Medicare |
$6,245.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,497.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,152.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,705.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,821.12
|
| Rate for Payer: Cash Price |
$6,691.20
|
| Rate for Payer: Cigna Commercial |
$20,519.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,481.32
|
| Rate for Payer: Health EOS Commercial |
$19,850.56
|
| Rate for Payer: HFN Commercial |
$20,519.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,728.00
|
| Rate for Payer: Multiplan Commercial |
$17,843.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,382.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,519.68
|
| Rate for Payer: Quartz Beloit One Network |
$10,928.96
|
| Rate for Payer: Quartz Commercial |
$14,497.60
|
| Rate for Payer: Quartz Medicare Advantage |
$13,382.40
|
| Rate for Payer: The Alliance Commercial |
$89,216.00
|
| Rate for Payer: WEA Trust Commercial |
$12,267.20
|
| Rate for Payer: WPS Commercial |
$16,520.57
|
|
|
H-PLATE MATRIX MIDFACE 11HL TI 04.503.352
|
Facility
|
IP
|
$22,304.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349487
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,928.96 |
| Max. Negotiated Rate |
$20,519.68 |
| Rate for Payer: Aetna Commercial |
$20,073.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,181.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,821.12
|
| Rate for Payer: Cash Price |
$6,691.20
|
| Rate for Payer: Cigna Commercial |
$20,519.68
|
| Rate for Payer: Health EOS Commercial |
$19,850.56
|
| Rate for Payer: HFN Commercial |
$20,519.68
|
| Rate for Payer: Multiplan Commercial |
$17,843.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,382.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,519.68
|
| Rate for Payer: Quartz Beloit One Network |
$10,928.96
|
| Rate for Payer: Quartz Commercial |
$13,382.40
|
| Rate for Payer: WEA Trust Commercial |
$12,267.20
|
| Rate for Payer: WPS Commercial |
$16,520.57
|
|
|
HPV 18/45
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 88142
|
| Hospital Charge Code |
4506951
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.41 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$65.40
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
HPV 18/45
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
CPT 88142
|
| Hospital Charge Code |
4506951
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.96 |
| Max. Negotiated Rate |
$103.55 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.40
|
| Rate for Payer: Health EOS Commercial |
$99.19
|
| Rate for Payer: HFN Commercial |
$103.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$71.52
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: Preferred Network Access Commercial |
$103.55
|
| Rate for Payer: Quartz Beloit One Network |
$47.96
|
| Rate for Payer: Quartz Commercial |
$62.13
|
| Rate for Payer: The Alliance Commercial |
$54.50
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
