|
Image Fusion RT
|
Facility
|
IP
|
$732.00
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
3040410
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$358.68 |
| Max. Negotiated Rate |
$673.44 |
| Rate for Payer: Aetna Commercial |
$658.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$629.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$387.96
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cigna Commercial |
$673.44
|
| Rate for Payer: Health EOS Commercial |
$651.48
|
| Rate for Payer: HFN Commercial |
$673.44
|
| Rate for Payer: Multiplan Commercial |
$585.60
|
| Rate for Payer: NAPHCARE Commercial |
$439.20
|
| Rate for Payer: Preferred Network Access Commercial |
$673.44
|
| Rate for Payer: Quartz Beloit One Network |
$358.68
|
| Rate for Payer: Quartz Commercial |
$439.20
|
| Rate for Payer: WEA Trust Commercial |
$402.60
|
| Rate for Payer: WPS Commercial |
$542.19
|
|
|
Image Fusion RT
|
Facility
|
OP
|
$732.00
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
3040410
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$204.96 |
| Max. Negotiated Rate |
$3,205.00 |
| Rate for Payer: Aetna Commercial |
$658.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$629.52
|
| Rate for Payer: Aetna Managed Medicare |
$204.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$387.96
|
| 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 |
$673.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$409.63
|
| Rate for Payer: Health EOS Commercial |
$651.48
|
| Rate for Payer: HFN Commercial |
$673.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$549.00
|
| Rate for Payer: Multiplan Commercial |
$585.60
|
| Rate for Payer: NAPHCARE Commercial |
$439.20
|
| Rate for Payer: Preferred Network Access Commercial |
$673.44
|
| Rate for Payer: Quartz Beloit One Network |
$358.68
|
| Rate for Payer: Quartz Commercial |
$475.80
|
| Rate for Payer: Quartz Medicare Advantage |
$439.20
|
| Rate for Payer: The Alliance Commercial |
$2,928.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$402.60
|
| Rate for Payer: WPS Commercial |
$542.19
|
|
|
Imaging Guidance RT
|
Facility
|
OP
|
$1,221.00
|
|
|
Service Code
|
CPT 77387
|
| Hospital Charge Code |
3883521
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$341.88 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$1,098.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.06
|
| Rate for Payer: Aetna Managed Medicare |
$341.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$793.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$610.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$586.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$647.13
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,123.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$683.27
|
| Rate for Payer: Health EOS Commercial |
$1,086.69
|
| Rate for Payer: HFN Commercial |
$1,123.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$915.75
|
| Rate for Payer: Multiplan Commercial |
$976.80
|
| Rate for Payer: NAPHCARE Commercial |
$732.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,123.32
|
| Rate for Payer: Quartz Beloit One Network |
$598.29
|
| Rate for Payer: Quartz Commercial |
$793.65
|
| Rate for Payer: Quartz Medicare Advantage |
$732.60
|
| Rate for Payer: The Alliance Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare PPO |
$915.75
|
| Rate for Payer: WEA Trust Commercial |
$671.55
|
| Rate for Payer: WPS Commercial |
$904.39
|
|
|
Imaging Guidance RT
|
Facility
|
IP
|
$1,221.00
|
|
|
Service Code
|
CPT 77387
|
| Hospital Charge Code |
3883521
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$598.29 |
| Max. Negotiated Rate |
$1,123.32 |
| Rate for Payer: Aetna Commercial |
$1,098.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,050.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$647.13
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,123.32
|
| Rate for Payer: Health EOS Commercial |
$1,086.69
|
| Rate for Payer: HFN Commercial |
$1,123.32
|
| Rate for Payer: Multiplan Commercial |
$976.80
|
| Rate for Payer: NAPHCARE Commercial |
$732.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,123.32
|
| Rate for Payer: Quartz Beloit One Network |
$598.29
|
| Rate for Payer: Quartz Commercial |
$732.60
|
| Rate for Payer: WEA Trust Commercial |
$671.55
|
| Rate for Payer: WPS Commercial |
$904.39
|
|
|
Imipramine Level
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$234.71 |
| Max. Negotiated Rate |
$440.68 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$287.40
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
Imipramine Level
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$134.12 |
| Max. Negotiated Rate |
$1,916.00 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Aetna Managed Medicare |
$134.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$311.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.05
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$359.25
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$311.35
|
| Rate for Payer: Quartz Medicare Advantage |
$287.40
|
| Rate for Payer: The Alliance Commercial |
$1,916.00
|
| Rate for Payer: United Healthcare PPO |
$359.25
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
Imipramine Level
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$455.05 |
| Rate for Payer: Aetna Commercial |
$455.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$455.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$287.40
|
| Rate for Payer: Health EOS Commercial |
$435.89
|
| Rate for Payer: HFN Commercial |
$455.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: Preferred Network Access Commercial |
$455.05
|
| Rate for Payer: Quartz Beloit One Network |
$210.76
|
| Rate for Payer: Quartz Commercial |
$273.03
|
| Rate for Payer: The Alliance Commercial |
$239.50
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
Imitrex 6 mg Charge
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.89 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Aetna Commercial |
$154.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$154.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.80
|
| Rate for Payer: Health EOS Commercial |
$148.33
|
| Rate for Payer: HFN Commercial |
$154.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$87.03
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: Preferred Network Access Commercial |
$154.85
|
| Rate for Payer: Quartz Beloit One Network |
$71.72
|
| Rate for Payer: Quartz Commercial |
$92.91
|
| Rate for Payer: The Alliance Commercial |
$81.50
|
| Rate for Payer: United Healthcare Medicaid |
$51.89
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
Imitrex 6 mg Charge
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.64 |
| Max. Negotiated Rate |
$652.00 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Aetna Managed Medicare |
$45.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.39
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.21
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$122.25
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$97.80
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$105.95
|
| Rate for Payer: Quartz Medicare Advantage |
$97.80
|
| Rate for Payer: The Alliance Commercial |
$652.00
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
Imitrex 6 mg Charge
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.87 |
| Max. Negotiated Rate |
$149.96 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.39
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$97.80
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$97.80
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
IMMOBILIZER HEAD STA-BLOK 700-00001
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2963960
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Aetna Managed Medicare |
$22.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.77
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$52.00
|
| Rate for Payer: Quartz Medicare Advantage |
$48.00
|
| Rate for Payer: The Alliance Commercial |
$320.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
IMMOBILIZER HEAD STA-BLOK 700-00001
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2963960
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$73.60 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
IMMUNE ADMIN ORAL/NASAL 90473
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
CPT 90473
|
| Hospital Charge Code |
3015323
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.76 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| 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 |
$27.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.40
|
| Rate for Payer: Health EOS Commercial |
$26.39
|
| Rate for Payer: HFN Commercial |
$27.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.68
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: Preferred Network Access Commercial |
$27.55
|
| Rate for Payer: Quartz Beloit One Network |
$12.76
|
| Rate for Payer: Quartz Commercial |
$16.53
|
| Rate for Payer: The Alliance Commercial |
$14.50
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
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 |
$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
|
|
|
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 |
$14.00 |
| 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
|
|
|
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 |
$17.87 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Aetna Commercial |
$47.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| 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 |
$47.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.00
|
| Rate for Payer: Health EOS Commercial |
$45.50
|
| Rate for Payer: HFN Commercial |
$47.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.87
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: Preferred Network Access Commercial |
$47.50
|
| Rate for Payer: Quartz Beloit One Network |
$22.00
|
| Rate for Payer: Quartz Commercial |
$28.50
|
| Rate for Payer: The Alliance Commercial |
$25.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
Immunization Admin 90471 man
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
3407519
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.68 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Aetna Commercial |
$92.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| 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 |
$92.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$88.27
|
| Rate for Payer: HFN Commercial |
$92.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.68
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.15
|
| Rate for Payer: Quartz Beloit One Network |
$42.68
|
| Rate for Payer: Quartz Commercial |
$55.29
|
| Rate for Payer: The Alliance Commercial |
$48.50
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
Immunization Admin 90471 man
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
3407519
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$46.56 |
| Max. Negotiated Rate |
$278.52 |
| Rate for Payer: Aetna Commercial |
$87.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.56
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$89.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$86.33
|
| Rate for Payer: HFN Commercial |
$89.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$89.24
|
| Rate for Payer: Quartz Beloit One Network |
$47.53
|
| Rate for Payer: Quartz Commercial |
$63.05
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: The Alliance Commercial |
$278.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$72.75
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
Immunization Admin 90471 man
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
3407519
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$47.53 |
| Max. Negotiated Rate |
$89.24 |
| Rate for Payer: Aetna Commercial |
$87.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.41
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$89.24
|
| Rate for Payer: Health EOS Commercial |
$86.33
|
| Rate for Payer: HFN Commercial |
$89.24
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: NAPHCARE Commercial |
$58.20
|
| Rate for Payer: Preferred Network Access Commercial |
$89.24
|
| Rate for Payer: Quartz Beloit One Network |
$47.53
|
| Rate for Payer: Quartz Commercial |
$58.20
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
Immunization Admin, Each Add 90472
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3382920
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Immunization Admin, Each Add 90472
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3382920
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: United Healthcare PPO |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Immunization Admin, Each Add 90472
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3382920
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$17.87 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| 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 |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.40
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: HFN Commercial |
$51.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.87
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Immunization Admin, Each Addl
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3575512
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Immunization Admin, Each Addl
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3575512
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$224.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: The Alliance Commercial |
$224.00
|
| Rate for Payer: United Healthcare PPO |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Immunoassay, Fibrospect II
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2776820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.96 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Aetna Commercial |
$315.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$285.52
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$315.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.20
|
| Rate for Payer: Health EOS Commercial |
$302.12
|
| Rate for Payer: HFN Commercial |
$315.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.96
|
| Rate for Payer: Multiplan Commercial |
$265.60
|
| Rate for Payer: Preferred Network Access Commercial |
$315.40
|
| Rate for Payer: Quartz Beloit One Network |
$146.08
|
| Rate for Payer: Quartz Commercial |
$189.24
|
| Rate for Payer: The Alliance Commercial |
$166.00
|
| Rate for Payer: WEA Trust Commercial |
$182.60
|
| Rate for Payer: WPS Commercial |
$245.91
|
|
