|
Non-Rebreather Mask - Adult
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
3040337
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
NON-ROUTINE BL DRAW OVER 3 YRS 36410
|
Professional
|
Both
|
$119.00
|
|
|
Service Code
|
CPT 36410
|
| Hospital Charge Code |
3014523
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Aetna Commercial |
$113.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.40
|
| Rate for Payer: Health EOS Commercial |
$108.29
|
| Rate for Payer: HFN Commercial |
$113.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.03
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: Preferred Network Access Commercial |
$113.05
|
| Rate for Payer: Quartz Beloit One Network |
$52.36
|
| Rate for Payer: Quartz Commercial |
$67.83
|
| Rate for Payer: The Alliance Commercial |
$59.50
|
| Rate for Payer: United Healthcare Medicaid |
$10.11
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC
|
Facility
|
IP
|
$28,549.00
|
|
|
Service Code
|
MSDRG 071
|
| Min. Negotiated Rate |
$10,269.57 |
| Max. Negotiated Rate |
$28,549.00 |
| Rate for Payer: Wellcare Medicare |
$10,269.57
|
| Rate for Payer: Aetna Managed Medicare |
$10,269.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,238.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,045.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,194.68
|
| Rate for Payer: Anthem Medicare Advantage |
$10,269.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,269.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,269.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,269.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,977.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,269.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,705.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,269.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,269.57
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,269.57
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,269.57
|
| Rate for Payer: NAPHCARE Commercial |
$15,404.36
|
| Rate for Payer: Quartz Medicare Advantage |
$10,269.57
|
| Rate for Payer: The Alliance Commercial |
$28,549.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,269.57
|
| Rate for Payer: United Healthcare PPO |
$16,119.19
|
|
|
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC
|
Facility
|
IP
|
$47,896.00
|
|
|
Service Code
|
MSDRG 070
|
| Min. Negotiated Rate |
$17,228.78 |
| Max. Negotiated Rate |
$47,896.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,228.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37,554.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,784.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,347.62
|
| Rate for Payer: Anthem Medicare Advantage |
$17,228.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,228.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,228.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,228.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,358.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,228.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,895.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,228.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,228.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,228.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,228.78
|
| Rate for Payer: NAPHCARE Commercial |
$25,843.17
|
| Rate for Payer: Quartz Medicare Advantage |
$17,228.78
|
| Rate for Payer: The Alliance Commercial |
$47,896.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,228.78
|
| Rate for Payer: United Healthcare PPO |
$27,166.40
|
| Rate for Payer: Wellcare Medicare |
$17,228.78
|
|
|
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$21,137.00
|
|
|
Service Code
|
MSDRG 072
|
| Min. Negotiated Rate |
$7,603.34 |
| Max. Negotiated Rate |
$21,137.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,603.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,364.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,543.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,916.84
|
| Rate for Payer: Anthem Medicare Advantage |
$7,603.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,603.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,603.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,603.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,228.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,603.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,268.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,603.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,603.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,603.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,603.34
|
| Rate for Payer: NAPHCARE Commercial |
$11,405.01
|
| Rate for Payer: Quartz Medicare Advantage |
$7,603.34
|
| Rate for Payer: The Alliance Commercial |
$21,137.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,603.34
|
| Rate for Payer: United Healthcare PPO |
$11,886.72
|
| Rate for Payer: Wellcare Medicare |
$7,603.34
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC
|
Facility
|
IP
|
$37,990.00
|
|
|
Service Code
|
MSDRG 067
|
| Min. Negotiated Rate |
$13,665.48 |
| Max. Negotiated Rate |
$37,990.00 |
| Rate for Payer: Aetna Managed Medicare |
$13,665.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,791.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,835.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,694.76
|
| Rate for Payer: Anthem Medicare Advantage |
$13,665.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,665.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,665.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,665.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,083.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,665.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,629.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,665.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,665.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,665.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,665.48
|
| Rate for Payer: NAPHCARE Commercial |
$20,498.22
|
| Rate for Payer: Quartz Medicare Advantage |
$13,665.48
|
| Rate for Payer: The Alliance Commercial |
$37,990.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,665.48
|
| Rate for Payer: United Healthcare PPO |
$21,509.96
|
| Rate for Payer: Wellcare Medicare |
$13,665.48
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC
|
Facility
|
IP
|
$23,477.00
|
|
|
Service Code
|
MSDRG 068
|
| Min. Negotiated Rate |
$8,444.89 |
| Max. Negotiated Rate |
$23,477.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,444.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,252.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,990.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,291.86
|
| Rate for Payer: Anthem Medicare Advantage |
$8,444.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,444.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,444.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,444.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,755.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,444.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,984.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,444.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,444.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,444.89
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,444.89
|
| Rate for Payer: NAPHCARE Commercial |
$12,667.34
|
| Rate for Payer: Quartz Medicare Advantage |
$8,444.89
|
| Rate for Payer: The Alliance Commercial |
$23,477.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,444.89
|
| Rate for Payer: United Healthcare PPO |
$13,222.65
|
| Rate for Payer: Wellcare Medicare |
$8,444.89
|
|
|
Non-State Supplied - Bexsero Charge
|
Professional
|
Both
|
$383.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.52 |
| Max. Negotiated Rate |
$363.85 |
| Rate for Payer: Aetna Commercial |
$363.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$363.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.80
|
| Rate for Payer: Health EOS Commercial |
$348.53
|
| Rate for Payer: HFN Commercial |
$363.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$286.95
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: Preferred Network Access Commercial |
$363.85
|
| Rate for Payer: Quartz Beloit One Network |
$168.52
|
| Rate for Payer: Quartz Commercial |
$218.31
|
| Rate for Payer: The Alliance Commercial |
$191.50
|
| Rate for Payer: United Healthcare Medicaid |
$226.32
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
Non-State Supplied - Bexsero Charge
|
Facility
|
OP
|
$383.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.24 |
| Max. Negotiated Rate |
$1,532.00 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Aetna Managed Medicare |
$107.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$191.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$214.33
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$287.25
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$229.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$248.95
|
| Rate for Payer: Quartz Medicare Advantage |
$229.80
|
| Rate for Payer: The Alliance Commercial |
$1,532.00
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
Non-State Supplied - Bexsero Charge
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.67 |
| Max. Negotiated Rate |
$352.36 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$229.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$229.80
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
Non-State Supplied - DTap Charge
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$38.40
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Non-State Supplied - DTap Charge
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.92 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Aetna Managed Medicare |
$17.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.81
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$41.60
|
| Rate for Payer: Quartz Medicare Advantage |
$38.40
|
| Rate for Payer: The Alliance Commercial |
$256.00
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Non-State Supplied - DTap Charge
|
Professional
|
Both
|
$64.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.40
|
| Rate for Payer: Health EOS Commercial |
$58.24
|
| Rate for Payer: HFN Commercial |
$60.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.16
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: Preferred Network Access Commercial |
$60.80
|
| Rate for Payer: Quartz Beloit One Network |
$28.16
|
| Rate for Payer: Quartz Commercial |
$36.48
|
| Rate for Payer: The Alliance Commercial |
$32.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Non-State Supplied - Dtap-Hep B-IPV Charge
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3912010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.84 |
| Max. Negotiated Rate |
$198.72 |
| Rate for Payer: Aetna Commercial |
$194.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.48
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$198.72
|
| Rate for Payer: Health EOS Commercial |
$192.24
|
| Rate for Payer: HFN Commercial |
$198.72
|
| Rate for Payer: Multiplan Commercial |
$172.80
|
| Rate for Payer: NAPHCARE Commercial |
$129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$198.72
|
| Rate for Payer: Quartz Beloit One Network |
$105.84
|
| Rate for Payer: Quartz Commercial |
$129.60
|
| Rate for Payer: WEA Trust Commercial |
$118.80
|
| Rate for Payer: WPS Commercial |
$159.99
|
|
|
Non-State Supplied - Dtap-Hep B-IPV Charge
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3912010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.48 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$194.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.76
|
| Rate for Payer: Aetna Managed Medicare |
$60.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$140.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$108.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$103.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.48
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$198.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.87
|
| Rate for Payer: Health EOS Commercial |
$192.24
|
| Rate for Payer: HFN Commercial |
$198.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$162.00
|
| Rate for Payer: Multiplan Commercial |
$172.80
|
| Rate for Payer: NAPHCARE Commercial |
$129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$198.72
|
| Rate for Payer: Quartz Beloit One Network |
$105.84
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: Quartz Medicare Advantage |
$129.60
|
| Rate for Payer: The Alliance Commercial |
$864.00
|
| Rate for Payer: WEA Trust Commercial |
$118.80
|
| Rate for Payer: WPS Commercial |
$159.99
|
|
|
Non-State Supplied - Dtap-Hep B-IPV Charge
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3912010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.76
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$205.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.60
|
| Rate for Payer: Health EOS Commercial |
$196.56
|
| Rate for Payer: HFN Commercial |
$205.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$179.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.49
|
| Rate for Payer: Multiplan Commercial |
$172.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.20
|
| Rate for Payer: Quartz Beloit One Network |
$95.04
|
| Rate for Payer: Quartz Commercial |
$123.12
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$118.80
|
| Rate for Payer: WPS Commercial |
$159.99
|
|
|
Non-State Supplied - DTaP-IPV Charge
|
Professional
|
Both
|
$147.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$139.65 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.20
|
| Rate for Payer: Health EOS Commercial |
$133.77
|
| Rate for Payer: HFN Commercial |
$139.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.84
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$139.65
|
| Rate for Payer: Quartz Beloit One Network |
$64.68
|
| Rate for Payer: Quartz Commercial |
$83.79
|
| Rate for Payer: The Alliance Commercial |
$73.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Non-State Supplied - DTaP-IPV Charge
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$588.00 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$41.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.26
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110.25
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$95.55
|
| Rate for Payer: Quartz Medicare Advantage |
$88.20
|
| Rate for Payer: The Alliance Commercial |
$588.00
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Non-State Supplied - DTaP-IPV Charge
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.03 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$88.20
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Non-State Supplied - Hep A Pediatric Charge
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$52.20
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
Non-State Supplied - Hep A Pediatric Charge
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Aetna Commercial |
$82.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$82.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.20
|
| Rate for Payer: Health EOS Commercial |
$79.17
|
| Rate for Payer: HFN Commercial |
$82.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.38
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: Preferred Network Access Commercial |
$82.65
|
| Rate for Payer: Quartz Beloit One Network |
$38.28
|
| Rate for Payer: Quartz Commercial |
$49.59
|
| Rate for Payer: The Alliance Commercial |
$43.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
Non-State Supplied - Hep A Pediatric Charge
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.36 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Aetna Managed Medicare |
$24.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$56.55
|
| Rate for Payer: Quartz Medicare Advantage |
$52.20
|
| Rate for Payer: The Alliance Commercial |
$348.00
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
Non-State Supplied - Hep B Ped/Adol Charge
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Non-State Supplied - Hep B Ped/Adol Charge
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.71
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$76.92
|
|
|
Non-State Supplied - Hep B Ped/Adol Charge
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.12 |
| Max. Negotiated Rate |
$81.85 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.77
|
| Rate for Payer: Health EOS Commercial |
$43.68
|
| Rate for Payer: HFN Commercial |
$45.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$41.20
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.60
|
| Rate for Payer: Quartz Beloit One Network |
$21.12
|
| Rate for Payer: Quartz Commercial |
$27.36
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: United Healthcare Medicaid |
$81.85
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$76.92
|
|
