|
Non-State Supplied - Pentacel Charge
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3513533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$303.60 |
| Rate for Payer: Aetna Commercial |
$297.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$303.60
|
| Rate for Payer: Health EOS Commercial |
$293.70
|
| Rate for Payer: HFN Commercial |
$303.60
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: NAPHCARE Commercial |
$198.00
|
| Rate for Payer: Preferred Network Access Commercial |
$303.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.70
|
| Rate for Payer: Quartz Commercial |
$198.00
|
| Rate for Payer: WEA Trust Commercial |
$181.50
|
| Rate for Payer: WPS Commercial |
$244.43
|
|
|
Non-State Supplied - Pentacel Charge
|
Professional
|
Both
|
$330.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3513533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$313.50 |
| Rate for Payer: Aetna Commercial |
$313.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.80
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$313.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.00
|
| Rate for Payer: Health EOS Commercial |
$300.30
|
| Rate for Payer: HFN Commercial |
$313.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.58
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: Preferred Network Access Commercial |
$313.50
|
| Rate for Payer: Quartz Beloit One Network |
$145.20
|
| Rate for Payer: Quartz Commercial |
$188.10
|
| Rate for Payer: The Alliance Commercial |
$165.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$181.50
|
| Rate for Payer: WPS Commercial |
$244.43
|
|
|
Non-State Supplied - Pneumococcal 23 Charge
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3013484
|
|
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 |
$54.60
|
| 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: 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 |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.81
|
|
|
Non-State Supplied - Pneumococcal 23 Charge
|
Professional
|
Both
|
$182.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3013484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$333.68 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.47
|
| Rate for Payer: Health EOS Commercial |
$165.62
|
| Rate for Payer: HFN Commercial |
$172.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$183.84
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| 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: The Alliance Commercial |
$91.00
|
| Rate for Payer: United Healthcare Medicaid |
$132.08
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$333.68
|
|
|
Non-State Supplied - Pneumococcal 23 Charge
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3013484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$728.00 |
| 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 |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$176.58
|
| 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 |
$728.00
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$333.68
|
|
|
Non-State Supplied - Polio Charge
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3023849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.24 |
| Max. Negotiated Rate |
$632.00 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Aetna Managed Medicare |
$44.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.42
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$118.50
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$102.70
|
| Rate for Payer: Quartz Medicare Advantage |
$94.80
|
| Rate for Payer: The Alliance Commercial |
$632.00
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Non-State Supplied - Polio Charge
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3023849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.42 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$94.80
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Non-State Supplied - Polio Charge
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3023849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.64 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Aetna Commercial |
$150.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$150.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.80
|
| Rate for Payer: Health EOS Commercial |
$143.78
|
| Rate for Payer: HFN Commercial |
$150.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.17
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.10
|
| Rate for Payer: Quartz Beloit One Network |
$69.52
|
| Rate for Payer: Quartz Commercial |
$90.06
|
| Rate for Payer: The Alliance Commercial |
$79.00
|
| Rate for Payer: United Healthcare Medicaid |
$55.64
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Non-State Supplied - Prevnar13 Charge
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3013470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.96 |
| Max. Negotiated Rate |
$1,528.00 |
| Rate for Payer: Aetna Commercial |
$343.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.52
|
| Rate for Payer: Aetna Managed Medicare |
$106.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$191.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.46
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$351.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.32
|
| Rate for Payer: Health EOS Commercial |
$339.98
|
| Rate for Payer: HFN Commercial |
$351.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.50
|
| Rate for Payer: Multiplan Commercial |
$305.60
|
| Rate for Payer: NAPHCARE Commercial |
$229.20
|
| Rate for Payer: Preferred Network Access Commercial |
$351.44
|
| Rate for Payer: Quartz Beloit One Network |
$187.18
|
| Rate for Payer: Quartz Commercial |
$248.30
|
| Rate for Payer: Quartz Medicare Advantage |
$229.20
|
| Rate for Payer: The Alliance Commercial |
$1,528.00
|
| Rate for Payer: WEA Trust Commercial |
$210.10
|
| Rate for Payer: WPS Commercial |
$644.97
|
|
|
Non-State Supplied - Prevnar13 Charge
|
Professional
|
Both
|
$382.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3013470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.08 |
| Max. Negotiated Rate |
$644.97 |
| Rate for Payer: Aetna Commercial |
$362.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.52
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$362.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$241.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.99
|
| Rate for Payer: Health EOS Commercial |
$347.62
|
| Rate for Payer: HFN Commercial |
$362.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$352.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$352.41
|
| Rate for Payer: Multiplan Commercial |
$305.60
|
| Rate for Payer: Preferred Network Access Commercial |
$362.90
|
| Rate for Payer: Quartz Beloit One Network |
$168.08
|
| Rate for Payer: Quartz Commercial |
$217.74
|
| Rate for Payer: The Alliance Commercial |
$191.00
|
| Rate for Payer: United Healthcare Medicaid |
$241.43
|
| Rate for Payer: WEA Trust Commercial |
$210.10
|
| Rate for Payer: WPS Commercial |
$644.97
|
|
|
Non-State Supplied - Prevnar13 Charge
|
Facility
|
IP
|
$382.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3013470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.18 |
| Max. Negotiated Rate |
$351.44 |
| Rate for Payer: Aetna Commercial |
$343.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.46
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$351.44
|
| Rate for Payer: Health EOS Commercial |
$339.98
|
| Rate for Payer: HFN Commercial |
$351.44
|
| Rate for Payer: Multiplan Commercial |
$305.60
|
| Rate for Payer: NAPHCARE Commercial |
$229.20
|
| Rate for Payer: Preferred Network Access Commercial |
$351.44
|
| Rate for Payer: Quartz Beloit One Network |
$187.18
|
| Rate for Payer: Quartz Commercial |
$229.20
|
| Rate for Payer: WEA Trust Commercial |
$210.10
|
| Rate for Payer: WPS Commercial |
$282.95
|
|
|
Non-State Supplied - Prevnar 20 Charge
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6159668
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.04 |
| Max. Negotiated Rate |
$745.09 |
| Rate for Payer: Aetna Commercial |
$228.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$228.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$268.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.04
|
| Rate for Payer: Health EOS Commercial |
$219.31
|
| Rate for Payer: HFN Commercial |
$228.95
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.95
|
| Rate for Payer: Quartz Beloit One Network |
$106.04
|
| Rate for Payer: Quartz Commercial |
$137.37
|
| Rate for Payer: The Alliance Commercial |
$120.50
|
| Rate for Payer: United Healthcare Medicaid |
$268.21
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$745.09
|
|
|
Non-State Supplied - Prevnar 20 Charge
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6159668
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.48 |
| Max. Negotiated Rate |
$964.00 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Aetna Managed Medicare |
$67.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.30
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.75
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$156.65
|
| Rate for Payer: Quartz Medicare Advantage |
$144.60
|
| Rate for Payer: The Alliance Commercial |
$964.00
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$745.09
|
|
|
Non-State Supplied - Prevnar 20 Charge
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6159668
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$144.60
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Non-State Supplied - Rotarix Charge
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.28 |
| Max. Negotiated Rate |
$1,304.00 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$91.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$211.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$163.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$156.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.43
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$244.50
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$211.90
|
| Rate for Payer: Quartz Medicare Advantage |
$195.60
|
| Rate for Payer: The Alliance Commercial |
$1,304.00
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Non-State Supplied - Rotarix Charge
|
Professional
|
Both
|
$326.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$309.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$309.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$195.60
|
| Rate for Payer: Health EOS Commercial |
$296.66
|
| Rate for Payer: HFN Commercial |
$309.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$211.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.23
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$309.70
|
| Rate for Payer: Quartz Beloit One Network |
$143.44
|
| Rate for Payer: Quartz Commercial |
$185.82
|
| Rate for Payer: The Alliance Commercial |
$163.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Non-State Supplied - Rotarix Charge
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$159.74 |
| Max. Negotiated Rate |
$299.92 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$195.60
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Non-State Supplied - Rotateq Charge
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.08 |
| Max. Negotiated Rate |
$444.00 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Aetna Managed Medicare |
$31.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.12
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.25
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$72.15
|
| Rate for Payer: Quartz Medicare Advantage |
$66.60
|
| Rate for Payer: The Alliance Commercial |
$444.00
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
Non-State Supplied - Rotateq Charge
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$102.12 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$66.60
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
Non-State Supplied - Rotateq Charge
|
Professional
|
Both
|
$111.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$146.06 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.60
|
| Rate for Payer: Health EOS Commercial |
$101.01
|
| Rate for Payer: HFN Commercial |
$105.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$146.06
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$105.45
|
| Rate for Payer: Quartz Beloit One Network |
$48.84
|
| Rate for Payer: Quartz Commercial |
$63.27
|
| Rate for Payer: The Alliance Commercial |
$55.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
Non-State Supplied - TDaP Charge
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$90.16 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$58.80
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
Non-State Supplied - TDaP Charge
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$97.72 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.09
|
| Rate for Payer: Health EOS Commercial |
$89.18
|
| Rate for Payer: HFN Commercial |
$93.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: Preferred Network Access Commercial |
$93.10
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$55.86
|
| Rate for Payer: The Alliance Commercial |
$49.00
|
| Rate for Payer: United Healthcare Medicaid |
$67.41
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$97.72
|
|
|
Non-State Supplied - TDaP Charge
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.71
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$97.72
|
|
|
Non-State Supplied - Td Charge
|
Professional
|
Both
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.83
|
| Rate for Payer: Health EOS Commercial |
$52.78
|
| Rate for Payer: HFN Commercial |
$55.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.65
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: Preferred Network Access Commercial |
$55.10
|
| Rate for Payer: Quartz Beloit One Network |
$25.52
|
| Rate for Payer: Quartz Commercial |
$33.06
|
| Rate for Payer: The Alliance Commercial |
$29.00
|
| Rate for Payer: United Healthcare Medicaid |
$54.74
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$47.07
|
|
|
Non-State Supplied - Td Charge
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.42 |
| Max. Negotiated Rate |
$53.36 |
| Rate for Payer: Aetna Commercial |
$52.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.74
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$53.36
|
| Rate for Payer: Health EOS Commercial |
$51.62
|
| Rate for Payer: HFN Commercial |
$53.36
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: NAPHCARE Commercial |
$34.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.36
|
| Rate for Payer: Quartz Beloit One Network |
$28.42
|
| Rate for Payer: Quartz Commercial |
$34.80
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$42.96
|
|
