|
Non-State Supplied - Pentacel Charge
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3513533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.17 |
| Max. Negotiated Rate |
$315.74 |
| Rate for Payer: Aetna Commercial |
$308.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$181.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$315.74
|
| Rate for Payer: Health EOS Commercial |
$305.45
|
| Rate for Payer: HFN Commercial |
$315.74
|
| Rate for Payer: Multiplan Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$315.74
|
| Rate for Payer: Quartz Beloit One Network |
$168.17
|
| Rate for Payer: Quartz Commercial |
$205.92
|
| Rate for Payer: WEA Trust Commercial |
$188.76
|
| Rate for Payer: WPS Commercial |
$254.20
|
|
|
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 |
$92.75 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
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 |
$83.28 |
| Max. Negotiated Rate |
$347.03 |
| Rate for Payer: Aetna Commercial |
$179.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$138.81
|
| Rate for Payer: Anthem Medicare Advantage |
$138.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$138.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$138.81
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$179.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.81
|
| Rate for Payer: Health EOS Commercial |
$172.24
|
| Rate for Payer: HFN Commercial |
$179.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$191.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$138.81
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$208.21
|
| Rate for Payer: Preferred Network Access Commercial |
$179.82
|
| Rate for Payer: Quartz Beloit One Network |
$83.28
|
| Rate for Payer: Quartz Commercial |
$107.89
|
| Rate for Payer: Quartz Medicare Advantage |
$138.81
|
| Rate for Payer: The Alliance Commercial |
$347.02
|
| Rate for Payer: United Healthcare Medicaid |
$121.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$138.81
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$347.03
|
|
|
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 |
$53.00 |
| Max. Negotiated Rate |
$555.24 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$53.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$123.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$183.64
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.96
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$113.57
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$123.03
|
| Rate for Payer: Quartz Medicare Advantage |
$113.57
|
| Rate for Payer: The Alliance Commercial |
$555.24
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$347.03
|
|
|
Non-State Supplied - Polio Charge
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3023849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.52 |
| Max. Negotiated Rate |
$156.10 |
| Rate for Payer: Aetna Commercial |
$156.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$156.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.59
|
| Rate for Payer: Health EOS Commercial |
$149.53
|
| Rate for Payer: HFN Commercial |
$156.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.62
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: Preferred Network Access Commercial |
$156.10
|
| Rate for Payer: Quartz Beloit One Network |
$72.30
|
| Rate for Payer: Quartz Commercial |
$93.66
|
| Rate for Payer: The Alliance Commercial |
$82.16
|
| Rate for Payer: United Healthcare Medicaid |
$46.52
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
Non-State Supplied - Polio Charge
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3023849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.01 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Aetna Managed Medicare |
$46.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.96
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.24
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: NAPHCARE Commercial |
$98.59
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$106.81
|
| Rate for Payer: Quartz Medicare Advantage |
$98.59
|
| Rate for Payer: The Alliance Commercial |
$82.16
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
Non-State Supplied - Polio Charge
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3023849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.52 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$98.59
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
Non-State Supplied - Prevnar13 Charge
|
Professional
|
Both
|
$382.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3013470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.80 |
| Max. Negotiated Rate |
$670.77 |
| Rate for Payer: Aetna Commercial |
$377.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.66
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$377.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$198.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.31
|
| Rate for Payer: Health EOS Commercial |
$361.52
|
| Rate for Payer: HFN Commercial |
$377.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$366.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$366.51
|
| Rate for Payer: Multiplan Commercial |
$317.82
|
| Rate for Payer: Preferred Network Access Commercial |
$377.42
|
| Rate for Payer: Quartz Beloit One Network |
$174.80
|
| Rate for Payer: Quartz Commercial |
$226.45
|
| Rate for Payer: The Alliance Commercial |
$198.64
|
| Rate for Payer: WEA Trust Commercial |
$218.50
|
| Rate for Payer: WPS Commercial |
$670.77
|
|
|
Non-State Supplied - Prevnar13 Charge
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3013470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.24 |
| Max. Negotiated Rate |
$670.77 |
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.66
|
| Rate for Payer: Aetna Managed Medicare |
$111.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$198.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$190.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.56
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$365.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$353.58
|
| Rate for Payer: HFN Commercial |
$365.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$297.96
|
| Rate for Payer: Multiplan Commercial |
$317.82
|
| Rate for Payer: NAPHCARE Commercial |
$238.37
|
| Rate for Payer: Preferred Network Access Commercial |
$365.50
|
| Rate for Payer: Quartz Beloit One Network |
$194.67
|
| Rate for Payer: Quartz Commercial |
$258.23
|
| Rate for Payer: Quartz Medicare Advantage |
$238.37
|
| Rate for Payer: The Alliance Commercial |
$198.64
|
| Rate for Payer: WEA Trust Commercial |
$218.50
|
| Rate for Payer: WPS Commercial |
$670.77
|
|
|
Non-State Supplied - Prevnar13 Charge
|
Facility
|
IP
|
$382.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3013470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$194.67 |
| Max. Negotiated Rate |
$365.50 |
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.56
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$365.50
|
| Rate for Payer: Health EOS Commercial |
$353.58
|
| Rate for Payer: HFN Commercial |
$365.50
|
| Rate for Payer: Multiplan Commercial |
$317.82
|
| Rate for Payer: Preferred Network Access Commercial |
$365.50
|
| Rate for Payer: Quartz Beloit One Network |
$194.67
|
| Rate for Payer: Quartz Commercial |
$238.37
|
| Rate for Payer: WEA Trust Commercial |
$218.50
|
| Rate for Payer: WPS Commercial |
$294.25
|
|
|
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 |
$110.28 |
| Max. Negotiated Rate |
$813.54 |
| Rate for Payer: Aetna Commercial |
$238.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$325.42
|
| Rate for Payer: Anthem Medicare Advantage |
$325.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$325.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$325.42
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$238.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$257.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.96
|
| Rate for Payer: Health EOS Commercial |
$228.08
|
| Rate for Payer: HFN Commercial |
$238.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$325.42
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$488.12
|
| Rate for Payer: Preferred Network Access Commercial |
$238.11
|
| Rate for Payer: Quartz Beloit One Network |
$110.28
|
| Rate for Payer: Quartz Commercial |
$142.86
|
| Rate for Payer: Quartz Medicare Advantage |
$325.42
|
| Rate for Payer: The Alliance Commercial |
$813.54
|
| Rate for Payer: United Healthcare Medicaid |
$257.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$325.42
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
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 |
$70.18 |
| Max. Negotiated Rate |
$1,301.66 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$70.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$125.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.07
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.98
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$150.38
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$162.92
|
| Rate for Payer: Quartz Medicare Advantage |
$150.38
|
| Rate for Payer: The Alliance Commercial |
$1,301.66
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
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 |
$122.81 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$150.38
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
Non-State Supplied - Rotarix Charge
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.13 |
| Max. Negotiated Rate |
$311.92 |
| Rate for Payer: Aetna Commercial |
$305.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.69
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$311.92
|
| Rate for Payer: Health EOS Commercial |
$301.75
|
| Rate for Payer: HFN Commercial |
$311.92
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: Preferred Network Access Commercial |
$311.92
|
| Rate for Payer: Quartz Beloit One Network |
$166.13
|
| Rate for Payer: Quartz Commercial |
$203.42
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
Non-State Supplied - Rotarix Charge
|
Professional
|
Both
|
$326.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.18 |
| Max. Negotiated Rate |
$322.09 |
| Rate for Payer: Aetna Commercial |
$322.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$322.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.42
|
| Rate for Payer: Health EOS Commercial |
$308.53
|
| Rate for Payer: HFN Commercial |
$322.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$219.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$219.68
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: Preferred Network Access Commercial |
$322.09
|
| Rate for Payer: Quartz Beloit One Network |
$149.18
|
| Rate for Payer: Quartz Commercial |
$193.25
|
| Rate for Payer: The Alliance Commercial |
$169.52
|
| Rate for Payer: United Healthcare Medicaid |
$152.90
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
Non-State Supplied - Rotarix Charge
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.93 |
| Max. Negotiated Rate |
$311.92 |
| Rate for Payer: Aetna Commercial |
$305.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Aetna Managed Medicare |
$94.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$220.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$169.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$162.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.69
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$311.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.73
|
| Rate for Payer: Health EOS Commercial |
$301.75
|
| Rate for Payer: HFN Commercial |
$311.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$254.28
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: NAPHCARE Commercial |
$203.42
|
| Rate for Payer: Preferred Network Access Commercial |
$311.92
|
| Rate for Payer: Quartz Beloit One Network |
$166.13
|
| Rate for Payer: Quartz Commercial |
$220.38
|
| Rate for Payer: Quartz Medicare Advantage |
$203.42
|
| Rate for Payer: The Alliance Commercial |
$169.52
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
Non-State Supplied - Rotateq Charge
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.57 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna Commercial |
$103.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.18
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$106.20
|
| Rate for Payer: Health EOS Commercial |
$102.74
|
| Rate for Payer: HFN Commercial |
$106.20
|
| Rate for Payer: Multiplan Commercial |
$92.35
|
| Rate for Payer: Preferred Network Access Commercial |
$106.20
|
| Rate for Payer: Quartz Beloit One Network |
$56.57
|
| Rate for Payer: Quartz Commercial |
$69.26
|
| Rate for Payer: WEA Trust Commercial |
$63.49
|
| Rate for Payer: WPS Commercial |
$85.50
|
|
|
Non-State Supplied - Rotateq Charge
|
Professional
|
Both
|
$111.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.79 |
| Max. Negotiated Rate |
$151.90 |
| Rate for Payer: Aetna Commercial |
$109.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.28
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$109.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$106.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.26
|
| Rate for Payer: Health EOS Commercial |
$105.05
|
| Rate for Payer: HFN Commercial |
$109.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$151.90
|
| Rate for Payer: Multiplan Commercial |
$92.35
|
| Rate for Payer: Preferred Network Access Commercial |
$109.67
|
| Rate for Payer: Quartz Beloit One Network |
$50.79
|
| Rate for Payer: Quartz Commercial |
$65.80
|
| Rate for Payer: The Alliance Commercial |
$57.72
|
| Rate for Payer: United Healthcare Medicaid |
$106.85
|
| Rate for Payer: WEA Trust Commercial |
$63.49
|
| Rate for Payer: WPS Commercial |
$85.50
|
|
|
Non-State Supplied - Rotateq Charge
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.32 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna Commercial |
$103.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.28
|
| Rate for Payer: Aetna Managed Medicare |
$32.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.18
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$106.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.60
|
| Rate for Payer: Health EOS Commercial |
$102.74
|
| Rate for Payer: HFN Commercial |
$106.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.58
|
| Rate for Payer: Multiplan Commercial |
$92.35
|
| Rate for Payer: NAPHCARE Commercial |
$69.26
|
| Rate for Payer: Preferred Network Access Commercial |
$106.20
|
| Rate for Payer: Quartz Beloit One Network |
$56.57
|
| Rate for Payer: Quartz Commercial |
$75.04
|
| Rate for Payer: Quartz Medicare Advantage |
$69.26
|
| Rate for Payer: The Alliance Commercial |
$57.72
|
| Rate for Payer: WEA Trust Commercial |
$63.49
|
| Rate for Payer: WPS Commercial |
$85.50
|
|
|
Non-State Supplied - TDaP Charge
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.65 |
| Max. Negotiated Rate |
$103.19 |
| Rate for Payer: Aetna Commercial |
$96.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$41.28
|
| Rate for Payer: Anthem Medicare Advantage |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.28
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$96.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.65
|
| Rate for Payer: Health EOS Commercial |
$92.75
|
| Rate for Payer: HFN Commercial |
$96.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.28
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.92
|
| Rate for Payer: Preferred Network Access Commercial |
$96.82
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$58.09
|
| Rate for Payer: Quartz Medicare Advantage |
$41.28
|
| Rate for Payer: The Alliance Commercial |
$103.19
|
| Rate for Payer: United Healthcare Medicaid |
$51.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.28
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$101.62
|
|
|
Non-State Supplied - TDaP Charge
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
Non-State Supplied - TDaP Charge
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$165.11 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$28.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.78
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.44
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.15
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.15
|
| Rate for Payer: The Alliance Commercial |
$165.11
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$101.62
|
|
|
Non-State Supplied - Td Charge
|
Professional
|
Both
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.58 |
| Max. Negotiated Rate |
$101.32 |
| Rate for Payer: Aetna Commercial |
$57.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$40.53
|
| Rate for Payer: Anthem Medicare Advantage |
$40.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$40.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$40.53
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$57.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.58
|
| Rate for Payer: Health EOS Commercial |
$54.89
|
| Rate for Payer: HFN Commercial |
$57.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$40.53
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$60.79
|
| Rate for Payer: Preferred Network Access Commercial |
$57.30
|
| Rate for Payer: Quartz Beloit One Network |
$26.54
|
| Rate for Payer: Quartz Commercial |
$34.38
|
| Rate for Payer: Quartz Medicare Advantage |
$40.53
|
| Rate for Payer: The Alliance Commercial |
$101.32
|
| Rate for Payer: United Healthcare Medicaid |
$43.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.53
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$48.95
|
|
|
Non-State Supplied - Td Charge
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$36.19
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
Non-State Supplied - Td Charge
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.89 |
| Max. Negotiated Rate |
$162.12 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$16.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.91
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.24
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$36.19
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$39.21
|
| Rate for Payer: Quartz Medicare Advantage |
$36.19
|
| Rate for Payer: The Alliance Commercial |
$162.12
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$48.95
|
|
