|
MMRV Vaccine, SC 90710
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3455570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.73 |
| Max. Negotiated Rate |
$376.98 |
| Rate for Payer: Aetna Commercial |
$368.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Aetna Managed Medicare |
$114.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$266.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$204.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$196.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.17
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$376.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.31
|
| Rate for Payer: Health EOS Commercial |
$364.69
|
| Rate for Payer: HFN Commercial |
$376.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$307.32
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: NAPHCARE Commercial |
$245.86
|
| Rate for Payer: Preferred Network Access Commercial |
$376.98
|
| Rate for Payer: Quartz Beloit One Network |
$200.78
|
| Rate for Payer: Quartz Commercial |
$266.34
|
| Rate for Payer: Quartz Medicare Advantage |
$245.86
|
| Rate for Payer: The Alliance Commercial |
$204.88
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
MMRV Vaccine, SC 90710
|
Professional
|
Both
|
$394.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3455570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.29 |
| Max. Negotiated Rate |
$424.40 |
| Rate for Payer: Aetna Commercial |
$389.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$389.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.86
|
| Rate for Payer: Health EOS Commercial |
$372.88
|
| Rate for Payer: HFN Commercial |
$389.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$424.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$424.40
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: Preferred Network Access Commercial |
$389.27
|
| Rate for Payer: Quartz Beloit One Network |
$180.29
|
| Rate for Payer: Quartz Commercial |
$233.56
|
| Rate for Payer: The Alliance Commercial |
$204.88
|
| Rate for Payer: United Healthcare Medicaid |
$300.74
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
MMRV Vaccine, SC 90710
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3455570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$200.78 |
| Max. Negotiated Rate |
$376.98 |
| Rate for Payer: Aetna Commercial |
$368.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.17
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$376.98
|
| Rate for Payer: Health EOS Commercial |
$364.69
|
| Rate for Payer: HFN Commercial |
$376.98
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: Preferred Network Access Commercial |
$376.98
|
| Rate for Payer: Quartz Beloit One Network |
$200.78
|
| Rate for Payer: Quartz Commercial |
$245.86
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
MMRV Vaccine, SC 90710 VFC Charge
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
5084632
|
|
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
|
|
|
MMRV Vaccine, SC 90710 VFC Charge
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
5084632
|
|
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
|
|
|
MMRV Vaccine, SC 90710 VFC Charge
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
5084632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$424.40 |
| 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 |
$300.74
|
| 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 |
$424.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$424.40
|
| 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: United Healthcare Medicaid |
$300.74
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$19,027.23
|
|
|
Service Code
|
APR-DRG 7933
|
| Min. Negotiated Rate |
$16,901.18 |
| Max. Negotiated Rate |
$19,027.23 |
| Rate for Payer: Anthem Medicaid |
$18,219.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$18,219.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18,219.62
|
| Rate for Payer: Dean Health Medicaid |
$18,219.62
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16,901.18
|
| Rate for Payer: Managed Health Services Medicaid |
$19,027.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,219.62
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18,219.62
|
| Rate for Payer: United Healthcare Medicaid |
$18,219.62
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$13,327.83
|
|
|
Service Code
|
APR-DRG 7932
|
| Min. Negotiated Rate |
$11,838.61 |
| Max. Negotiated Rate |
$13,327.83 |
| Rate for Payer: Anthem Medicaid |
$12,762.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,762.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,762.13
|
| Rate for Payer: Dean Health Medicaid |
$12,762.13
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,838.61
|
| Rate for Payer: Managed Health Services Medicaid |
$13,327.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,762.13
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,762.13
|
| Rate for Payer: United Healthcare Medicaid |
$12,762.13
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$9,995.87
|
|
|
Service Code
|
APR-DRG 7931
|
| Min. Negotiated Rate |
$8,878.96 |
| Max. Negotiated Rate |
$9,995.87 |
| Rate for Payer: Anthem Medicaid |
$9,571.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,571.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,571.60
|
| Rate for Payer: Dean Health Medicaid |
$9,571.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,878.96
|
| Rate for Payer: Managed Health Services Medicaid |
$9,995.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,571.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,571.60
|
| Rate for Payer: United Healthcare Medicaid |
$9,571.60
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$33,144.21
|
|
|
Service Code
|
APR-DRG 7934
|
| Min. Negotiated Rate |
$29,440.76 |
| Max. Negotiated Rate |
$33,144.21 |
| Rate for Payer: Anthem Medicaid |
$31,737.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$31,737.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31,737.41
|
| Rate for Payer: Dean Health Medicaid |
$31,737.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$29,440.76
|
| Rate for Payer: Managed Health Services Medicaid |
$33,144.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$31,737.41
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$31,737.41
|
| Rate for Payer: United Healthcare Medicaid |
$31,737.41
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$22,183.82
|
|
|
Service Code
|
APR-DRG 9513
|
| Min. Negotiated Rate |
$19,705.06 |
| Max. Negotiated Rate |
$22,183.82 |
| Rate for Payer: Anthem Medicaid |
$21,242.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$21,242.23
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21,242.23
|
| Rate for Payer: Dean Health Medicaid |
$21,242.23
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19,705.06
|
| Rate for Payer: Managed Health Services Medicaid |
$22,183.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$21,242.23
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$21,242.23
|
| Rate for Payer: United Healthcare Medicaid |
$21,242.23
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$15,081.49
|
|
|
Service Code
|
APR-DRG 9512
|
| Min. Negotiated Rate |
$13,396.32 |
| Max. Negotiated Rate |
$15,081.49 |
| Rate for Payer: Anthem Medicaid |
$14,441.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$14,441.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14,441.36
|
| Rate for Payer: Dean Health Medicaid |
$14,441.36
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13,396.32
|
| Rate for Payer: Managed Health Services Medicaid |
$15,081.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,441.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14,441.36
|
| Rate for Payer: United Healthcare Medicaid |
$14,441.36
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$36,739.22
|
|
|
Service Code
|
APR-DRG 9514
|
| Min. Negotiated Rate |
$32,634.07 |
| Max. Negotiated Rate |
$36,739.22 |
| Rate for Payer: Anthem Medicaid |
$35,179.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$35,179.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35,179.83
|
| Rate for Payer: Dean Health Medicaid |
$35,179.83
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$32,634.07
|
| Rate for Payer: Managed Health Services Medicaid |
$36,739.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$35,179.83
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$35,179.83
|
| Rate for Payer: United Healthcare Medicaid |
$35,179.83
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$10,434.29
|
|
|
Service Code
|
APR-DRG 9511
|
| Min. Negotiated Rate |
$9,268.39 |
| Max. Negotiated Rate |
$10,434.29 |
| Rate for Payer: Anthem Medicaid |
$9,991.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,991.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,991.41
|
| Rate for Payer: Dean Health Medicaid |
$9,991.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9,268.39
|
| Rate for Payer: Managed Health Services Medicaid |
$10,434.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,991.41
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,991.41
|
| Rate for Payer: United Healthcare Medicaid |
$9,991.41
|
|
|
Moderna 25mcg/0.25mL (6m-11yr) - Covid Vaccine
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6219808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$382.36 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$152.94
|
| Rate for Payer: Anthem Medicare Advantage |
$152.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$152.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$152.94
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.76
|
| Rate for Payer: Health EOS Commercial |
$165.62
|
| Rate for Payer: HFN Commercial |
$172.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$152.94
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$229.41
|
| Rate for Payer: Preferred Network Access Commercial |
$172.90
|
| Rate for Payer: Quartz Beloit One Network |
$80.08
|
| Rate for Payer: Quartz Commercial |
$103.74
|
| Rate for Payer: Quartz Medicare Advantage |
$152.94
|
| Rate for Payer: The Alliance Commercial |
$382.36
|
| Rate for Payer: United Healthcare Medicaid |
$134.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.94
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$379.39
|
|
|
Moderna 25mcg/0.25mL (6m-11yr) - Covid Vaccine
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6219808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$611.77 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$50.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$118.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.77
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.50
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$118.30
|
| Rate for Payer: Quartz Medicare Advantage |
$109.20
|
| Rate for Payer: The Alliance Commercial |
$611.77
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$379.39
|
|
|
Moderna 25mcg/0.25mL (6m-11yr) - Covid Vaccine
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6219808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.18 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
Moderna 50mcg/0.5mL (12 yr & older) - Covid Vaccine
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6219809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$420.29 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$168.12
|
| Rate for Payer: Anthem Medicare Advantage |
$168.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.12
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$147.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.76
|
| Rate for Payer: Health EOS Commercial |
$165.62
|
| Rate for Payer: HFN Commercial |
$172.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.12
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$252.17
|
| Rate for Payer: Preferred Network Access Commercial |
$172.90
|
| Rate for Payer: Quartz Beloit One Network |
$80.08
|
| Rate for Payer: Quartz Commercial |
$103.74
|
| Rate for Payer: Quartz Medicare Advantage |
$168.12
|
| Rate for Payer: The Alliance Commercial |
$420.29
|
| Rate for Payer: United Healthcare Medicaid |
$147.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.12
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$379.39
|
|
|
Moderna 50mcg/0.5mL (12 yr & older) - Covid Vaccine
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6219809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$672.46 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$50.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$118.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.77
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.50
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$118.30
|
| Rate for Payer: Quartz Medicare Advantage |
$109.20
|
| Rate for Payer: The Alliance Commercial |
$672.46
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$379.39
|
|
|
Moderna 50mcg/0.5mL (12 yr & older) - Covid Vaccine
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6219809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.18 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
Mod Sed Same Phys/QHP Each Addl 15 Mins 99153
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
5160609
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.79 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$51.17
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
Mod Sed Same Phys/QHP Each Addl 15 Mins 99153
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
5160609
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.72
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$51.17
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$55.43
|
| Rate for Payer: Quartz Medicare Advantage |
$51.17
|
| Rate for Payer: The Alliance Commercial |
$47.47
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
.MOG Antibody Titer, Serum
|
Facility
|
IP
|
$686.00
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
6243839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$349.59 |
| Max. Negotiated Rate |
$656.36 |
| Rate for Payer: Aetna Commercial |
$642.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$613.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$378.12
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cigna Commercial |
$656.36
|
| Rate for Payer: Health EOS Commercial |
$634.96
|
| Rate for Payer: HFN Commercial |
$656.36
|
| Rate for Payer: Multiplan Commercial |
$570.75
|
| Rate for Payer: Preferred Network Access Commercial |
$656.36
|
| Rate for Payer: Quartz Beloit One Network |
$349.59
|
| Rate for Payer: Quartz Commercial |
$428.06
|
| Rate for Payer: WEA Trust Commercial |
$392.39
|
| Rate for Payer: WPS Commercial |
$528.43
|
|
|
.MOG Antibody Titer, Serum
|
Facility
|
OP
|
$686.00
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
6243839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$656.36 |
| Rate for Payer: Aetna Commercial |
$642.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$613.56
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$378.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cigna Commercial |
$656.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$399.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$634.96
|
| Rate for Payer: HFN Commercial |
$656.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$570.75
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$656.36
|
| Rate for Payer: Quartz Beloit One Network |
$349.59
|
| Rate for Payer: Quartz Commercial |
$463.74
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$535.08
|
| Rate for Payer: WEA Trust Commercial |
$392.39
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$528.43
|
|
|
.MOG Antibody Titer, Serum
|
Professional
|
Both
|
$686.00
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
6243839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$677.77 |
| Rate for Payer: Aetna Commercial |
$677.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$613.56
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cigna Commercial |
$677.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$356.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$649.23
|
| Rate for Payer: HFN Commercial |
$677.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$570.75
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$677.77
|
| Rate for Payer: Quartz Beloit One Network |
$313.91
|
| Rate for Payer: Quartz Commercial |
$406.66
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$392.39
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
