|
Homovanillic Acid, Random Urine
|
Facility
|
OP
|
$46.59
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
4076076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$44.58 |
| Rate for Payer: Aetna Commercial |
$43.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.67
|
| Rate for Payer: Aetna Managed Medicare |
$5.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.39
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cigna Commercial |
$44.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.39
|
| Rate for Payer: Health EOS Commercial |
$43.12
|
| Rate for Payer: HFN Commercial |
$44.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.39
|
| Rate for Payer: Multiplan Commercial |
$38.76
|
| Rate for Payer: NAPHCARE Commercial |
$8.08
|
| Rate for Payer: Preferred Network Access Commercial |
$44.58
|
| Rate for Payer: Quartz Beloit One Network |
$23.74
|
| Rate for Payer: Quartz Commercial |
$31.49
|
| Rate for Payer: Quartz Medicare Advantage |
$5.39
|
| Rate for Payer: The Alliance Commercial |
$21.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.39
|
| Rate for Payer: United Healthcare PPO |
$36.34
|
| Rate for Payer: WEA Trust Commercial |
$26.65
|
| Rate for Payer: Wellcare Medicare |
$5.39
|
| Rate for Payer: WPS Commercial |
$35.89
|
|
|
Homovanillic Acid, Random Urine
|
Facility
|
IP
|
$46.59
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
4076076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.74 |
| Max. Negotiated Rate |
$44.58 |
| Rate for Payer: Aetna Commercial |
$43.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.68
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cigna Commercial |
$44.58
|
| Rate for Payer: Health EOS Commercial |
$43.12
|
| Rate for Payer: HFN Commercial |
$44.58
|
| Rate for Payer: Multiplan Commercial |
$38.76
|
| Rate for Payer: Preferred Network Access Commercial |
$44.58
|
| Rate for Payer: Quartz Beloit One Network |
$23.74
|
| Rate for Payer: Quartz Commercial |
$29.07
|
| Rate for Payer: WEA Trust Commercial |
$26.65
|
| Rate for Payer: WPS Commercial |
$35.89
|
|
|
Homovanillic Acid, Random Urine
|
Professional
|
Both
|
$46.59
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
4076076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$46.03 |
| Rate for Payer: Aetna Commercial |
$46.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.67
|
| Rate for Payer: Aetna Managed Medicare |
$5.39
|
| Rate for Payer: Anthem Medicare Advantage |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.39
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cigna Commercial |
$46.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.39
|
| Rate for Payer: Health EOS Commercial |
$44.09
|
| Rate for Payer: HFN Commercial |
$46.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.39
|
| Rate for Payer: Multiplan Commercial |
$38.76
|
| Rate for Payer: NAPHCARE Commercial |
$8.08
|
| Rate for Payer: Preferred Network Access Commercial |
$46.03
|
| Rate for Payer: Quartz Beloit One Network |
$21.32
|
| Rate for Payer: Quartz Commercial |
$27.62
|
| Rate for Payer: Quartz Medicare Advantage |
$5.39
|
| Rate for Payer: The Alliance Commercial |
$21.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.39
|
| Rate for Payer: WEA Trust Commercial |
$26.65
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
HOOK BLUNT 5MM 3316-8G
|
Facility
|
OP
|
$171.00
|
|
| Hospital Charge Code |
2964998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.80 |
| Max. Negotiated Rate |
$163.61 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.94
|
| Rate for Payer: Aetna Managed Medicare |
$49.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$88.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.26
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$163.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.52
|
| Rate for Payer: Health EOS Commercial |
$158.28
|
| Rate for Payer: HFN Commercial |
$163.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.38
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: NAPHCARE Commercial |
$106.70
|
| Rate for Payer: Preferred Network Access Commercial |
$163.61
|
| Rate for Payer: Quartz Beloit One Network |
$87.14
|
| Rate for Payer: Quartz Commercial |
$115.60
|
| Rate for Payer: Quartz Medicare Advantage |
$106.70
|
| Rate for Payer: The Alliance Commercial |
$88.92
|
| Rate for Payer: WEA Trust Commercial |
$97.81
|
| Rate for Payer: WPS Commercial |
$131.72
|
|
|
HOOK BLUNT 5MM 3316-8G
|
Facility
|
IP
|
$171.00
|
|
| Hospital Charge Code |
2964998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$87.14 |
| Max. Negotiated Rate |
$163.61 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.26
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$163.61
|
| Rate for Payer: Health EOS Commercial |
$158.28
|
| Rate for Payer: HFN Commercial |
$163.61
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: Preferred Network Access Commercial |
$163.61
|
| Rate for Payer: Quartz Beloit One Network |
$87.14
|
| Rate for Payer: Quartz Commercial |
$106.70
|
| Rate for Payer: WEA Trust Commercial |
$97.81
|
| Rate for Payer: WPS Commercial |
$131.72
|
|
|
HOOK SELF ADHESIVE VELCRO 1 25yd #7011-02-25"
|
Facility
|
OP
|
$50.00
|
|
| Hospital Charge Code |
2971376
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$14.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$31.20
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$33.80
|
| Rate for Payer: Quartz Medicare Advantage |
$31.20
|
| Rate for Payer: The Alliance Commercial |
$26.00
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
HOOK SELF ADHESIVE VELCRO 1 25yd #7011-02-25"
|
Facility
|
IP
|
$50.00
|
|
| Hospital Charge Code |
2971376
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
HOOK SHARP 5MM 3311-8G
|
Facility
|
IP
|
$178.00
|
|
| Hospital Charge Code |
2964997
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$111.07
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
HOOK SHARP 5MM 3311-8G
|
Facility
|
OP
|
$178.00
|
|
| Hospital Charge Code |
2964997
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.83 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Aetna Managed Medicare |
$51.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.60
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.84
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: NAPHCARE Commercial |
$111.07
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$120.33
|
| Rate for Payer: Quartz Medicare Advantage |
$111.07
|
| Rate for Payer: The Alliance Commercial |
$92.56
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
HOOK-UP DSD SCOPES HI-DEF #HU0068
|
Facility
|
OP
|
$4,978.00
|
|
| Hospital Charge Code |
2973556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,449.59 |
| Max. Negotiated Rate |
$4,762.95 |
| Rate for Payer: Aetna Commercial |
$4,659.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,452.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,449.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,365.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,588.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,485.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,743.87
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,762.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,897.20
|
| Rate for Payer: Health EOS Commercial |
$4,607.64
|
| Rate for Payer: HFN Commercial |
$4,762.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,882.84
|
| Rate for Payer: Multiplan Commercial |
$4,141.70
|
| Rate for Payer: NAPHCARE Commercial |
$3,106.27
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,536.79
|
| Rate for Payer: Quartz Commercial |
$3,365.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,106.27
|
| Rate for Payer: The Alliance Commercial |
$2,588.56
|
| Rate for Payer: WEA Trust Commercial |
$2,847.42
|
| Rate for Payer: WPS Commercial |
$3,834.55
|
|
|
HOOK-UP DSD SCOPES HI-DEF #HU0068
|
Facility
|
IP
|
$4,978.00
|
|
| Hospital Charge Code |
2973556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,536.79 |
| Max. Negotiated Rate |
$4,762.95 |
| Rate for Payer: Aetna Commercial |
$4,659.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,452.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,743.87
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,762.95
|
| Rate for Payer: Health EOS Commercial |
$4,607.64
|
| Rate for Payer: HFN Commercial |
$4,762.95
|
| Rate for Payer: Multiplan Commercial |
$4,141.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,536.79
|
| Rate for Payer: Quartz Commercial |
$3,106.27
|
| Rate for Payer: WEA Trust Commercial |
$2,847.42
|
| Rate for Payer: WPS Commercial |
$3,834.55
|
|
|
HOOKUP FOR DSD-201 HU0069
|
Facility
|
OP
|
$5,139.00
|
|
| Hospital Charge Code |
2973566
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,496.48 |
| Max. Negotiated Rate |
$4,917.00 |
| Rate for Payer: Aetna Commercial |
$4,810.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,596.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,496.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,473.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,672.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,565.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,832.62
|
| Rate for Payer: Cash Price |
$1,541.70
|
| Rate for Payer: Cigna Commercial |
$4,917.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,990.90
|
| Rate for Payer: Health EOS Commercial |
$4,756.66
|
| Rate for Payer: HFN Commercial |
$4,917.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,008.42
|
| Rate for Payer: Multiplan Commercial |
$4,275.65
|
| Rate for Payer: NAPHCARE Commercial |
$3,206.74
|
| Rate for Payer: Preferred Network Access Commercial |
$4,917.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,618.83
|
| Rate for Payer: Quartz Commercial |
$3,473.96
|
| Rate for Payer: Quartz Medicare Advantage |
$3,206.74
|
| Rate for Payer: The Alliance Commercial |
$2,672.28
|
| Rate for Payer: WEA Trust Commercial |
$2,939.51
|
| Rate for Payer: WPS Commercial |
$3,958.57
|
|
|
HOOKUP FOR DSD-201 HU0069
|
Facility
|
IP
|
$5,139.00
|
|
| Hospital Charge Code |
2973566
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,618.83 |
| Max. Negotiated Rate |
$4,917.00 |
| Rate for Payer: Aetna Commercial |
$4,810.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,596.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,832.62
|
| Rate for Payer: Cash Price |
$1,541.70
|
| Rate for Payer: Cigna Commercial |
$4,917.00
|
| Rate for Payer: Health EOS Commercial |
$4,756.66
|
| Rate for Payer: HFN Commercial |
$4,917.00
|
| Rate for Payer: Multiplan Commercial |
$4,275.65
|
| Rate for Payer: Preferred Network Access Commercial |
$4,917.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,618.83
|
| Rate for Payer: Quartz Commercial |
$3,206.74
|
| Rate for Payer: WEA Trust Commercial |
$2,939.51
|
| Rate for Payer: WPS Commercial |
$3,958.57
|
|
|
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 |
$242.07 |
| Max. Negotiated Rate |
$522.65 |
| Rate for Payer: Aetna Commercial |
$522.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$522.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$275.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.10
|
| Rate for Payer: Health EOS Commercial |
$500.65
|
| Rate for Payer: HFN Commercial |
$522.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$277.04
|
| Rate for Payer: Multiplan Commercial |
$440.13
|
| Rate for Payer: Preferred Network Access Commercial |
$522.65
|
| Rate for Payer: Quartz Beloit One Network |
$242.07
|
| Rate for Payer: Quartz Commercial |
$313.59
|
| Rate for Payer: The Alliance Commercial |
$275.08
|
| Rate for Payer: WEA Trust Commercial |
$302.59
|
| Rate for Payer: WPS Commercial |
$407.49
|
|
|
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 |
$154.04 |
| Max. Negotiated Rate |
$506.15 |
| Rate for Payer: Aetna Commercial |
$495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| Rate for Payer: Aetna Managed Medicare |
$154.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$357.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$275.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$264.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$291.58
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$506.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$307.88
|
| Rate for Payer: Health EOS Commercial |
$489.64
|
| Rate for Payer: HFN Commercial |
$506.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$412.62
|
| Rate for Payer: Multiplan Commercial |
$440.13
|
| Rate for Payer: NAPHCARE Commercial |
$330.10
|
| Rate for Payer: Preferred Network Access Commercial |
$506.15
|
| Rate for Payer: Quartz Beloit One Network |
$269.58
|
| Rate for Payer: Quartz Commercial |
$357.60
|
| Rate for Payer: Quartz Medicare Advantage |
$330.10
|
| Rate for Payer: The Alliance Commercial |
$275.08
|
| Rate for Payer: WEA Trust Commercial |
$302.59
|
| Rate for Payer: WPS Commercial |
$407.49
|
|
|
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 |
$269.58 |
| Max. Negotiated Rate |
$506.15 |
| Rate for Payer: Aetna Commercial |
$495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$291.58
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$506.15
|
| Rate for Payer: Health EOS Commercial |
$489.64
|
| Rate for Payer: HFN Commercial |
$506.15
|
| Rate for Payer: Multiplan Commercial |
$440.13
|
| Rate for Payer: Preferred Network Access Commercial |
$506.15
|
| Rate for Payer: Quartz Beloit One Network |
$269.58
|
| Rate for Payer: Quartz Commercial |
$330.10
|
| Rate for Payer: WEA Trust Commercial |
$302.59
|
| Rate for Payer: WPS Commercial |
$407.49
|
|
|
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 |
$10.61 |
| 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
|
|
|
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 |
$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
|
|
|
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 |
$9.53 |
| Max. Negotiated Rate |
$277.04 |
| 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 |
$10.83
|
| 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 |
$277.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$277.04
|
| 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: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$1,699.01 |
| Max. Negotiated Rate |
$3,189.97 |
| Rate for Payer: Aetna Commercial |
$3,120.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,981.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,837.70
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cigna Commercial |
$3,189.97
|
| Rate for Payer: Health EOS Commercial |
$3,085.95
|
| Rate for Payer: HFN Commercial |
$3,189.97
|
| Rate for Payer: Multiplan Commercial |
$2,773.89
|
| Rate for Payer: Preferred Network Access Commercial |
$3,189.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,699.01
|
| Rate for Payer: Quartz Commercial |
$2,080.42
|
| Rate for Payer: WEA Trust Commercial |
$1,907.05
|
| Rate for Payer: WPS Commercial |
$2,568.18
|
|
|
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 |
$970.86 |
| Max. Negotiated Rate |
$3,189.97 |
| Rate for Payer: Aetna Commercial |
$3,120.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,981.93
|
| Rate for Payer: Aetna Managed Medicare |
$970.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,253.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,733.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,664.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,837.70
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cigna Commercial |
$3,189.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,940.39
|
| Rate for Payer: Health EOS Commercial |
$3,085.95
|
| Rate for Payer: HFN Commercial |
$3,189.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,600.52
|
| Rate for Payer: Multiplan Commercial |
$2,773.89
|
| Rate for Payer: NAPHCARE Commercial |
$2,080.42
|
| Rate for Payer: Preferred Network Access Commercial |
$3,189.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,699.01
|
| Rate for Payer: Quartz Commercial |
$2,253.78
|
| Rate for Payer: Quartz Medicare Advantage |
$2,080.42
|
| Rate for Payer: The Alliance Commercial |
$1,733.68
|
| Rate for Payer: WEA Trust Commercial |
$1,907.05
|
| Rate for Payer: WPS Commercial |
$2,568.18
|
|
|
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 |
$1,699.01 |
| Max. Negotiated Rate |
$3,189.97 |
| Rate for Payer: Aetna Commercial |
$3,120.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,981.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,837.70
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cigna Commercial |
$3,189.97
|
| Rate for Payer: Health EOS Commercial |
$3,085.95
|
| Rate for Payer: HFN Commercial |
$3,189.97
|
| Rate for Payer: Multiplan Commercial |
$2,773.89
|
| Rate for Payer: Preferred Network Access Commercial |
$3,189.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,699.01
|
| Rate for Payer: Quartz Commercial |
$2,080.42
|
| Rate for Payer: WEA Trust Commercial |
$1,907.05
|
| Rate for Payer: WPS Commercial |
$2,568.18
|
|
|
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 |
$970.86 |
| Max. Negotiated Rate |
$3,189.97 |
| Rate for Payer: Aetna Commercial |
$3,120.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,981.93
|
| Rate for Payer: Aetna Managed Medicare |
$970.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,253.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,733.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,664.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,837.70
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cigna Commercial |
$3,189.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,940.39
|
| Rate for Payer: Health EOS Commercial |
$3,085.95
|
| Rate for Payer: HFN Commercial |
$3,189.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,600.52
|
| Rate for Payer: Multiplan Commercial |
$2,773.89
|
| Rate for Payer: NAPHCARE Commercial |
$2,080.42
|
| Rate for Payer: Preferred Network Access Commercial |
$3,189.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,699.01
|
| Rate for Payer: Quartz Commercial |
$2,253.78
|
| Rate for Payer: Quartz Medicare Advantage |
$2,080.42
|
| Rate for Payer: The Alliance Commercial |
$1,733.68
|
| Rate for Payer: WEA Trust Commercial |
$1,907.05
|
| Rate for Payer: WPS Commercial |
$2,568.18
|
|
|
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 |
$11,366.12 |
| Max. Negotiated Rate |
$21,340.47 |
| Rate for Payer: Aetna Commercial |
$20,876.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,948.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,293.96
|
| Rate for Payer: Cash Price |
$6,691.20
|
| Rate for Payer: Cigna Commercial |
$21,340.47
|
| Rate for Payer: Health EOS Commercial |
$20,644.58
|
| Rate for Payer: HFN Commercial |
$21,340.47
|
| Rate for Payer: Multiplan Commercial |
$18,556.93
|
| Rate for Payer: Preferred Network Access Commercial |
$21,340.47
|
| Rate for Payer: Quartz Beloit One Network |
$11,366.12
|
| Rate for Payer: Quartz Commercial |
$13,917.70
|
| Rate for Payer: WEA Trust Commercial |
$12,757.89
|
| Rate for Payer: WPS Commercial |
$17,180.77
|
|
|
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 |
$6,494.92 |
| Max. Negotiated Rate |
$21,340.47 |
| Rate for Payer: Aetna Commercial |
$20,876.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,948.70
|
| Rate for Payer: Aetna Managed Medicare |
$6,494.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,077.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,598.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,134.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,293.96
|
| Rate for Payer: Cash Price |
$6,691.20
|
| Rate for Payer: Cigna Commercial |
$21,340.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,980.93
|
| Rate for Payer: Health EOS Commercial |
$20,644.58
|
| Rate for Payer: HFN Commercial |
$21,340.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,397.12
|
| Rate for Payer: Multiplan Commercial |
$18,556.93
|
| Rate for Payer: NAPHCARE Commercial |
$13,917.70
|
| Rate for Payer: Preferred Network Access Commercial |
$21,340.47
|
| Rate for Payer: Quartz Beloit One Network |
$11,366.12
|
| Rate for Payer: Quartz Commercial |
$15,077.50
|
| Rate for Payer: Quartz Medicare Advantage |
$13,917.70
|
| Rate for Payer: The Alliance Commercial |
$11,598.08
|
| Rate for Payer: WEA Trust Commercial |
$12,757.89
|
| Rate for Payer: WPS Commercial |
$17,180.77
|
|
