|
Iloperidone Level
|
Facility
|
OP
|
$634.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
5581590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$184.62 |
| Max. Negotiated Rate |
$606.61 |
| Rate for Payer: Aetna Commercial |
$593.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$567.05
|
| Rate for Payer: Aetna Managed Medicare |
$184.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$428.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$329.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$316.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$349.46
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$606.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$368.99
|
| Rate for Payer: Health EOS Commercial |
$586.83
|
| Rate for Payer: HFN Commercial |
$606.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$494.52
|
| Rate for Payer: Multiplan Commercial |
$527.49
|
| Rate for Payer: NAPHCARE Commercial |
$395.62
|
| Rate for Payer: Preferred Network Access Commercial |
$606.61
|
| Rate for Payer: Quartz Beloit One Network |
$323.09
|
| Rate for Payer: Quartz Commercial |
$428.58
|
| Rate for Payer: Quartz Medicare Advantage |
$395.62
|
| Rate for Payer: The Alliance Commercial |
$329.68
|
| Rate for Payer: United Healthcare PPO |
$494.52
|
| Rate for Payer: WEA Trust Commercial |
$362.65
|
| Rate for Payer: WPS Commercial |
$488.37
|
|
|
Iloperidone Level
|
Facility
|
IP
|
$634.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
5581590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$323.09 |
| Max. Negotiated Rate |
$606.61 |
| Rate for Payer: Aetna Commercial |
$593.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$567.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$349.46
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$586.83
|
| Rate for Payer: HFN Commercial |
$606.61
|
| Rate for Payer: Multiplan Commercial |
$527.49
|
| Rate for Payer: Preferred Network Access Commercial |
$606.61
|
| Rate for Payer: Quartz Beloit One Network |
$323.09
|
| Rate for Payer: Quartz Commercial |
$395.62
|
| Rate for Payer: WEA Trust Commercial |
$362.65
|
| Rate for Payer: WPS Commercial |
$488.37
|
|
|
Iloperidone Level
|
Professional
|
Both
|
$634.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
5581590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$626.39 |
| Rate for Payer: Aetna Commercial |
$626.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$567.05
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$626.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$329.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$395.62
|
| Rate for Payer: Health EOS Commercial |
$600.02
|
| Rate for Payer: HFN Commercial |
$626.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$527.49
|
| Rate for Payer: Preferred Network Access Commercial |
$626.39
|
| Rate for Payer: Quartz Beloit One Network |
$290.12
|
| Rate for Payer: Quartz Commercial |
$375.84
|
| Rate for Payer: The Alliance Commercial |
$329.68
|
| Rate for Payer: WEA Trust Commercial |
$362.65
|
| Rate for Payer: WPS Commercial |
$488.37
|
|
|
Image Fusion RT
|
Facility
|
IP
|
$732.00
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
3040410
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$373.03 |
| Max. Negotiated Rate |
$700.38 |
| Rate for Payer: Aetna Commercial |
$685.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$654.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$403.48
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cigna Commercial |
$700.38
|
| Rate for Payer: Health EOS Commercial |
$677.54
|
| Rate for Payer: HFN Commercial |
$700.38
|
| Rate for Payer: Multiplan Commercial |
$609.02
|
| Rate for Payer: Preferred Network Access Commercial |
$700.38
|
| Rate for Payer: Quartz Beloit One Network |
$373.03
|
| Rate for Payer: Quartz Commercial |
$456.77
|
| Rate for Payer: WEA Trust Commercial |
$418.70
|
| Rate for Payer: WPS Commercial |
$563.86
|
|
|
Image Fusion RT
|
Facility
|
OP
|
$732.00
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
3040410
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$213.16 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$685.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$654.70
|
| Rate for Payer: Aetna Managed Medicare |
$213.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$403.48
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cigna Commercial |
$700.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$426.02
|
| Rate for Payer: Health EOS Commercial |
$677.54
|
| Rate for Payer: HFN Commercial |
$700.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$570.96
|
| Rate for Payer: Multiplan Commercial |
$609.02
|
| Rate for Payer: NAPHCARE Commercial |
$456.77
|
| Rate for Payer: Preferred Network Access Commercial |
$700.38
|
| Rate for Payer: Quartz Beloit One Network |
$373.03
|
| Rate for Payer: Quartz Commercial |
$494.83
|
| Rate for Payer: Quartz Medicare Advantage |
$456.77
|
| Rate for Payer: The Alliance Commercial |
$312.33
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$418.70
|
| Rate for Payer: WPS Commercial |
$546.58
|
|
|
Imaging Guidance RT
|
Facility
|
OP
|
$1,221.00
|
|
|
Service Code
|
CPT 77387
|
| Hospital Charge Code |
3883521
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$146.35 |
| Max. Negotiated Rate |
$1,168.25 |
| Rate for Payer: Aetna Commercial |
$1,142.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Aetna Managed Medicare |
$355.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$825.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$634.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$609.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$673.02
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,168.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$710.62
|
| Rate for Payer: Health EOS Commercial |
$1,130.16
|
| Rate for Payer: HFN Commercial |
$1,168.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$952.38
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: NAPHCARE Commercial |
$761.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,168.25
|
| Rate for Payer: Quartz Beloit One Network |
$622.22
|
| Rate for Payer: Quartz Commercial |
$825.40
|
| Rate for Payer: Quartz Medicare Advantage |
$761.90
|
| Rate for Payer: The Alliance Commercial |
$146.35
|
| Rate for Payer: United Healthcare PPO |
$952.38
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$940.54
|
|
|
Imaging Guidance RT
|
Facility
|
IP
|
$1,221.00
|
|
|
Service Code
|
CPT 77387
|
| Hospital Charge Code |
3883521
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$622.22 |
| Max. Negotiated Rate |
$1,168.25 |
| Rate for Payer: Aetna Commercial |
$1,142.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$673.02
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,168.25
|
| Rate for Payer: Health EOS Commercial |
$1,130.16
|
| Rate for Payer: HFN Commercial |
$1,168.25
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,168.25
|
| Rate for Payer: Quartz Beloit One Network |
$622.22
|
| Rate for Payer: Quartz Commercial |
$761.90
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$940.54
|
|
|
Imipramine Level
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$473.25 |
| Rate for Payer: Aetna Commercial |
$473.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$473.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$249.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.90
|
| Rate for Payer: Health EOS Commercial |
$453.33
|
| Rate for Payer: HFN Commercial |
$473.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$473.25
|
| Rate for Payer: Quartz Beloit One Network |
$219.19
|
| Rate for Payer: Quartz Commercial |
$283.95
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Imipramine Level
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$244.10 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$298.90
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Imipramine Level
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.48 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Aetna Managed Medicare |
$139.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$239.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.78
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$373.62
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: NAPHCARE Commercial |
$298.90
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$323.80
|
| Rate for Payer: Quartz Medicare Advantage |
$298.90
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: United Healthcare PPO |
$373.62
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Imitrex 6 mg Charge
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.47 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$47.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.87
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.14
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$101.71
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$101.71
|
| Rate for Payer: The Alliance Commercial |
$84.76
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
Imitrex 6 mg Charge
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.97 |
| Max. Negotiated Rate |
$161.04 |
| Rate for Payer: Aetna Commercial |
$161.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$161.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.71
|
| Rate for Payer: Health EOS Commercial |
$154.26
|
| Rate for Payer: HFN Commercial |
$161.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$90.51
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$161.04
|
| Rate for Payer: Quartz Beloit One Network |
$74.59
|
| Rate for Payer: Quartz Commercial |
$96.63
|
| Rate for Payer: The Alliance Commercial |
$84.76
|
| Rate for Payer: United Healthcare Medicaid |
$53.97
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
Imitrex 6 mg Charge
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
IMMOBILIZER HEAD STA-BLOK 700-00001
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2963960
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
IMMOBILIZER HEAD STA-BLOK 700-00001
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2963960
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
IMMUNE ADMIN ORAL/NASAL 90473
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
CPT 90473
|
| Hospital Charge Code |
3015323
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$69.31 |
| Rate for Payer: Aetna Commercial |
$28.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Aetna Managed Medicare |
$17.33
|
| Rate for Payer: Anthem Medicare Advantage |
$17.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.33
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$28.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.33
|
| Rate for Payer: Health EOS Commercial |
$27.45
|
| Rate for Payer: HFN Commercial |
$28.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.33
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: NAPHCARE Commercial |
$25.99
|
| Rate for Payer: Preferred Network Access Commercial |
$28.65
|
| Rate for Payer: Quartz Beloit One Network |
$13.27
|
| Rate for Payer: Quartz Commercial |
$17.19
|
| Rate for Payer: Quartz Medicare Advantage |
$17.33
|
| Rate for Payer: The Alliance Commercial |
$43.32
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.33
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$69.31
|
|
|
Immune Admin Oral/Nasal Addl 90474
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 90474
|
| Hospital Charge Code |
3507508
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$49.21 |
| 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: 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 |
$49.21
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Immune Admin Oral/Nasal Addl 90474
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
CPT 90474
|
| Hospital Charge Code |
3507508
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Aetna Commercial |
$49.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$12.30
|
| Rate for Payer: Anthem Medicare Advantage |
$12.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.30
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$49.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.30
|
| Rate for Payer: Health EOS Commercial |
$47.32
|
| Rate for Payer: HFN Commercial |
$49.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.30
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$18.45
|
| Rate for Payer: Preferred Network Access Commercial |
$49.40
|
| Rate for Payer: Quartz Beloit One Network |
$22.88
|
| Rate for Payer: Quartz Commercial |
$29.64
|
| Rate for Payer: Quartz Medicare Advantage |
$12.30
|
| Rate for Payer: The Alliance Commercial |
$30.76
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.30
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$49.21
|
|
|
Immune Admin Oral/Nasal Addl 90474
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 90474
|
| Hospital Charge Code |
3507508
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
Immunization Admin 90471 man
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
3407519
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$48.42 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$90.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.76
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.42
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$89.78
|
| Rate for Payer: HFN Commercial |
$92.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$80.70
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$92.81
|
| Rate for Payer: Quartz Beloit One Network |
$49.43
|
| Rate for Payer: Quartz Commercial |
$65.57
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$75.66
|
| Rate for Payer: WEA Trust Commercial |
$55.48
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$74.72
|
|
|
Immunization Admin 90471 man
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
3407519
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$95.84 |
| Rate for Payer: Aetna Commercial |
$95.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.76
|
| Rate for Payer: Aetna Managed Medicare |
$21.99
|
| Rate for Payer: Anthem Medicare Advantage |
$21.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.99
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$95.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.99
|
| Rate for Payer: Health EOS Commercial |
$91.80
|
| Rate for Payer: HFN Commercial |
$95.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.99
|
| Rate for Payer: Multiplan Commercial |
$80.70
|
| Rate for Payer: NAPHCARE Commercial |
$32.98
|
| Rate for Payer: Preferred Network Access Commercial |
$95.84
|
| Rate for Payer: Quartz Beloit One Network |
$44.39
|
| Rate for Payer: Quartz Commercial |
$57.50
|
| Rate for Payer: Quartz Medicare Advantage |
$21.99
|
| Rate for Payer: The Alliance Commercial |
$54.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.99
|
| Rate for Payer: WEA Trust Commercial |
$55.48
|
| Rate for Payer: WPS Commercial |
$87.94
|
|
|
Immunization Admin 90471 man
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
3407519
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$49.43 |
| Max. Negotiated Rate |
$92.81 |
| Rate for Payer: Aetna Commercial |
$90.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.47
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.81
|
| Rate for Payer: Health EOS Commercial |
$89.78
|
| Rate for Payer: HFN Commercial |
$92.81
|
| Rate for Payer: Multiplan Commercial |
$80.70
|
| Rate for Payer: Preferred Network Access Commercial |
$92.81
|
| Rate for Payer: Quartz Beloit One Network |
$49.43
|
| Rate for Payer: Quartz Commercial |
$60.53
|
| Rate for Payer: WEA Trust Commercial |
$55.48
|
| Rate for Payer: WPS Commercial |
$74.72
|
|
|
Immunization Admin, Each Add 90472
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3382920
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Immunization Admin, Each Add 90472
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3382920
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$63.86
|
|
|
Immunization Admin, Each Add 90472
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3382920
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.72 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
