|
NON-HYPOVOLEMIC SODIUM DISORDERS
|
Facility
|
IP
|
$5,874.77
|
|
|
Service Code
|
APR-DRG 4262
|
| Min. Negotiated Rate |
$5,218.34 |
| Max. Negotiated Rate |
$5,874.77 |
| Rate for Payer: Anthem Medicaid |
$5,625.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,625.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,625.41
|
| Rate for Payer: Dean Health Medicaid |
$5,625.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,218.34
|
| Rate for Payer: Managed Health Services Medicaid |
$5,874.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,625.41
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,625.41
|
| Rate for Payer: United Healthcare Medicaid |
$5,625.41
|
|
|
NON-HYPOVOLEMIC SODIUM DISORDERS
|
Facility
|
IP
|
$15,958.32
|
|
|
Service Code
|
APR-DRG 4264
|
| Min. Negotiated Rate |
$14,175.18 |
| Max. Negotiated Rate |
$15,958.32 |
| Rate for Payer: Anthem Medicaid |
$15,280.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$15,280.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15,280.97
|
| Rate for Payer: Dean Health Medicaid |
$15,280.97
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14,175.18
|
| Rate for Payer: Managed Health Services Medicaid |
$15,958.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,280.97
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15,280.97
|
| Rate for Payer: United Healthcare Medicaid |
$15,280.97
|
|
|
NONINVASIVE VENTILATION SUPPORT
|
Facility
|
OP
|
$30.66
|
|
|
Service Code
|
EAPG 02020
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$30.66 |
| Rate for Payer: Anthem Medicaid |
$29.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$29.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.48
|
| Rate for Payer: Dean Health Medicaid |
$29.48
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$29.48
|
| Rate for Payer: Managed Health Services Medicaid |
$30.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$29.48
|
| Rate for Payer: United Healthcare Medicaid |
$29.48
|
|
|
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC
|
Facility
|
IP
|
$28,687.36
|
|
|
Service Code
|
MSDRG 600
|
| Min. Negotiated Rate |
$8,483.56 |
| Max. Negotiated Rate |
$28,687.36 |
| Rate for Payer: Aetna Managed Medicare |
$8,483.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,726.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,419.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,550.11
|
| Rate for Payer: Anthem Medicare Advantage |
$8,483.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,483.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,483.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,483.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,372.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,483.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,797.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,483.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,483.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,483.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,483.56
|
| Rate for Payer: NAPHCARE Commercial |
$12,725.34
|
| Rate for Payer: Quartz Medicare Advantage |
$8,483.56
|
| Rate for Payer: The Alliance Commercial |
$28,687.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,483.56
|
| Rate for Payer: United Healthcare PPO |
$16,190.84
|
| Rate for Payer: Wellcare Medicare |
$8,483.56
|
|
|
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$17,849.52
|
|
|
Service Code
|
MSDRG 601
|
| Min. Negotiated Rate |
$5,140.00 |
| Max. Negotiated Rate |
$17,849.52 |
| Rate for Payer: Aetna Managed Medicare |
$5,140.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,200.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,118.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,612.92
|
| Rate for Payer: Anthem Medicare Advantage |
$5,140.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,140.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,140.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,140.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,671.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,140.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,626.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,140.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,140.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,140.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,140.00
|
| Rate for Payer: NAPHCARE Commercial |
$7,710.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5,140.00
|
| Rate for Payer: The Alliance Commercial |
$17,849.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,140.00
|
| Rate for Payer: United Healthcare PPO |
$9,829.76
|
| Rate for Payer: Wellcare Medicare |
$5,140.00
|
|
|
NON-PRESSURE CHRONIC SKIN ULCERS
|
Facility
|
OP
|
$28.12
|
|
|
Service Code
|
EAPG 00670
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Anthem Medicaid |
$27.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$27.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.04
|
| Rate for Payer: Dean Health Medicaid |
$27.04
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$27.04
|
| Rate for Payer: Managed Health Services Medicaid |
$28.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$27.04
|
| Rate for Payer: United Healthcare Medicaid |
$27.04
|
|
|
Non-Rebreather Mask - Adult
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
3040337
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.25
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
|
Non-Rebreather Mask - Adult
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
3040337
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Aetna Managed Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.16
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: NAPHCARE Commercial |
$1.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1.25
|
| Rate for Payer: The Alliance Commercial |
$1.04
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
|
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 |
$7.80 |
| Max. Negotiated Rate |
$117.57 |
| Rate for Payer: Aetna Commercial |
$117.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Aetna Managed Medicare |
$7.80
|
| Rate for Payer: Anthem Medicare Advantage |
$7.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.80
|
| 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 |
$117.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.80
|
| Rate for Payer: Health EOS Commercial |
$112.62
|
| Rate for Payer: HFN Commercial |
$117.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: NAPHCARE Commercial |
$11.70
|
| Rate for Payer: Preferred Network Access Commercial |
$117.57
|
| Rate for Payer: Quartz Beloit One Network |
$54.45
|
| Rate for Payer: Quartz Commercial |
$70.54
|
| Rate for Payer: Quartz Medicare Advantage |
$7.80
|
| Rate for Payer: The Alliance Commercial |
$33.15
|
| Rate for Payer: United Healthcare Medicaid |
$10.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.80
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: WPS Commercial |
$35.10
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION
|
Facility
|
IP
|
$11,398.80
|
|
|
Service Code
|
APR-DRG 0463
|
| Min. Negotiated Rate |
$10,125.13 |
| Max. Negotiated Rate |
$11,398.80 |
| Rate for Payer: Anthem Medicaid |
$10,914.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$10,914.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,914.98
|
| Rate for Payer: Dean Health Medicaid |
$10,914.98
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10,125.13
|
| Rate for Payer: Managed Health Services Medicaid |
$11,398.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,914.98
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10,914.98
|
| Rate for Payer: United Healthcare Medicaid |
$10,914.98
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION
|
Facility
|
IP
|
$20,517.85
|
|
|
Service Code
|
APR-DRG 0464
|
| Min. Negotiated Rate |
$18,225.23 |
| Max. Negotiated Rate |
$20,517.85 |
| Rate for Payer: Anthem Medicaid |
$19,646.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,646.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,646.97
|
| Rate for Payer: Dean Health Medicaid |
$19,646.97
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18,225.23
|
| Rate for Payer: Managed Health Services Medicaid |
$20,517.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,646.97
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,646.97
|
| Rate for Payer: United Healthcare Medicaid |
$19,646.97
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION
|
Facility
|
IP
|
$8,768.31
|
|
|
Service Code
|
APR-DRG 0462
|
| Min. Negotiated Rate |
$7,788.56 |
| Max. Negotiated Rate |
$8,768.31 |
| Rate for Payer: Anthem Medicaid |
$8,396.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,396.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,396.14
|
| Rate for Payer: Dean Health Medicaid |
$8,396.14
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,788.56
|
| Rate for Payer: Managed Health Services Medicaid |
$8,768.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,396.14
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,396.14
|
| Rate for Payer: United Healthcare Medicaid |
$8,396.14
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION
|
Facility
|
IP
|
$7,102.33
|
|
|
Service Code
|
APR-DRG 0461
|
| Min. Negotiated Rate |
$6,308.73 |
| Max. Negotiated Rate |
$7,102.33 |
| Rate for Payer: Anthem Medicaid |
$6,800.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,800.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,800.87
|
| Rate for Payer: Dean Health Medicaid |
$6,800.87
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6,308.73
|
| Rate for Payer: Managed Health Services Medicaid |
$7,102.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,800.87
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,800.87
|
| Rate for Payer: United Healthcare Medicaid |
$6,800.87
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION W/O INFARC
|
Facility
|
OP
|
$26.38
|
|
|
Service Code
|
EAPG 00534
|
| Min. Negotiated Rate |
$25.37 |
| Max. Negotiated Rate |
$26.38 |
| Rate for Payer: Anthem Medicaid |
$25.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$25.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.37
|
| Rate for Payer: Dean Health Medicaid |
$25.37
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$25.37
|
| Rate for Payer: Managed Health Services Medicaid |
$26.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.37
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$25.37
|
| Rate for Payer: United Healthcare Medicaid |
$25.37
|
|
|
Non-State Supplied - Bexsero Charge
|
Professional
|
Both
|
$383.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$175.26 |
| Max. Negotiated Rate |
$378.40 |
| Rate for Payer: Aetna Commercial |
$378.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.56
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$378.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$246.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.99
|
| Rate for Payer: Health EOS Commercial |
$362.47
|
| Rate for Payer: HFN Commercial |
$378.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$298.43
|
| Rate for Payer: Multiplan Commercial |
$318.66
|
| Rate for Payer: Preferred Network Access Commercial |
$378.40
|
| Rate for Payer: Quartz Beloit One Network |
$175.26
|
| Rate for Payer: Quartz Commercial |
$227.04
|
| Rate for Payer: The Alliance Commercial |
$199.16
|
| Rate for Payer: United Healthcare Medicaid |
$246.62
|
| Rate for Payer: WEA Trust Commercial |
$219.08
|
| Rate for Payer: WPS Commercial |
$295.02
|
|
|
Non-State Supplied - Bexsero Charge
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$195.18 |
| Max. Negotiated Rate |
$366.45 |
| Rate for Payer: Aetna Commercial |
$358.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$211.11
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$366.45
|
| Rate for Payer: Health EOS Commercial |
$354.50
|
| Rate for Payer: HFN Commercial |
$366.45
|
| Rate for Payer: Multiplan Commercial |
$318.66
|
| Rate for Payer: Preferred Network Access Commercial |
$366.45
|
| Rate for Payer: Quartz Beloit One Network |
$195.18
|
| Rate for Payer: Quartz Commercial |
$238.99
|
| Rate for Payer: WEA Trust Commercial |
$219.08
|
| Rate for Payer: WPS Commercial |
$295.02
|
|
|
Non-State Supplied - Bexsero Charge
|
Facility
|
OP
|
$383.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.53 |
| Max. Negotiated Rate |
$366.45 |
| Rate for Payer: Aetna Commercial |
$358.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.56
|
| Rate for Payer: Aetna Managed Medicare |
$111.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$199.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$191.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$211.11
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$366.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.91
|
| Rate for Payer: Health EOS Commercial |
$354.50
|
| Rate for Payer: HFN Commercial |
$366.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.74
|
| Rate for Payer: Multiplan Commercial |
$318.66
|
| Rate for Payer: NAPHCARE Commercial |
$238.99
|
| Rate for Payer: Preferred Network Access Commercial |
$366.45
|
| Rate for Payer: Quartz Beloit One Network |
$195.18
|
| Rate for Payer: Quartz Commercial |
$258.91
|
| Rate for Payer: Quartz Medicare Advantage |
$238.99
|
| Rate for Payer: The Alliance Commercial |
$199.16
|
| Rate for Payer: WEA Trust Commercial |
$219.08
|
| Rate for Payer: WPS Commercial |
$295.02
|
|
|
Non-State Supplied - DTap Charge
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$61.24 |
| Rate for Payer: Aetna Commercial |
$59.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.28
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$61.24
|
| Rate for Payer: Health EOS Commercial |
$59.24
|
| Rate for Payer: HFN Commercial |
$61.24
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: Preferred Network Access Commercial |
$61.24
|
| Rate for Payer: Quartz Beloit One Network |
$32.61
|
| Rate for Payer: Quartz Commercial |
$39.94
|
| Rate for Payer: WEA Trust Commercial |
$36.61
|
| Rate for Payer: WPS Commercial |
$49.30
|
|
|
Non-State Supplied - DTap Charge
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$61.24 |
| Rate for Payer: Aetna Commercial |
$59.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.24
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.28
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$61.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.25
|
| Rate for Payer: Health EOS Commercial |
$59.24
|
| Rate for Payer: HFN Commercial |
$61.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.92
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: NAPHCARE Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$61.24
|
| Rate for Payer: Quartz Beloit One Network |
$32.61
|
| Rate for Payer: Quartz Commercial |
$43.26
|
| Rate for Payer: Quartz Medicare Advantage |
$39.94
|
| Rate for Payer: The Alliance Commercial |
$33.28
|
| Rate for Payer: WEA Trust Commercial |
$36.61
|
| Rate for Payer: WPS Commercial |
$49.30
|
|
|
Non-State Supplied - DTap Charge
|
Professional
|
Both
|
$64.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.29 |
| Max. Negotiated Rate |
$63.23 |
| Rate for Payer: Aetna Commercial |
$63.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.24
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$63.23
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.94
|
| Rate for Payer: Health EOS Commercial |
$60.57
|
| Rate for Payer: HFN Commercial |
$63.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.89
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: Preferred Network Access Commercial |
$63.23
|
| Rate for Payer: Quartz Beloit One Network |
$29.29
|
| Rate for Payer: Quartz Commercial |
$37.94
|
| Rate for Payer: The Alliance Commercial |
$33.28
|
| Rate for Payer: United Healthcare Medicaid |
$31.61
|
| Rate for Payer: WEA Trust Commercial |
$36.61
|
| Rate for Payer: WPS Commercial |
$49.30
|
|
|
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 |
$98.84 |
| Max. Negotiated Rate |
$213.41 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$213.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.78
|
| Rate for Payer: Health EOS Commercial |
$204.42
|
| Rate for Payer: HFN Commercial |
$213.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$186.67
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: Preferred Network Access Commercial |
$213.41
|
| Rate for Payer: Quartz Beloit One Network |
$98.84
|
| Rate for Payer: Quartz Commercial |
$128.04
|
| Rate for Payer: The Alliance Commercial |
$112.32
|
| Rate for Payer: United Healthcare Medicaid |
$107.76
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: WPS Commercial |
$166.38
|
|
|
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 |
$110.07 |
| Max. Negotiated Rate |
$206.67 |
| Rate for Payer: Aetna Commercial |
$202.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.06
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$206.67
|
| Rate for Payer: Health EOS Commercial |
$199.93
|
| Rate for Payer: HFN Commercial |
$206.67
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: Preferred Network Access Commercial |
$206.67
|
| Rate for Payer: Quartz Beloit One Network |
$110.07
|
| Rate for Payer: Quartz Commercial |
$134.78
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: WPS Commercial |
$166.38
|
|
|
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 |
$62.90 |
| Max. Negotiated Rate |
$206.67 |
| Rate for Payer: Aetna Commercial |
$202.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Aetna Managed Medicare |
$62.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$146.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$112.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$107.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.06
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$206.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.71
|
| Rate for Payer: Health EOS Commercial |
$199.93
|
| Rate for Payer: HFN Commercial |
$206.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$168.48
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: NAPHCARE Commercial |
$134.78
|
| Rate for Payer: Preferred Network Access Commercial |
$206.67
|
| Rate for Payer: Quartz Beloit One Network |
$110.07
|
| Rate for Payer: Quartz Commercial |
$146.02
|
| Rate for Payer: Quartz Medicare Advantage |
$134.78
|
| Rate for Payer: The Alliance Commercial |
$112.32
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: WPS Commercial |
$166.38
|
|
|
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 |
$74.91 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.03
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$91.73
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
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 |
$67.15 |
| Max. Negotiated Rate |
$145.24 |
| Rate for Payer: Aetna Commercial |
$145.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$145.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.73
|
| Rate for Payer: Health EOS Commercial |
$139.12
|
| Rate for Payer: HFN Commercial |
$145.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.15
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$145.24
|
| Rate for Payer: Quartz Beloit One Network |
$67.27
|
| Rate for Payer: Quartz Commercial |
$87.14
|
| Rate for Payer: The Alliance Commercial |
$76.44
|
| Rate for Payer: United Healthcare Medicaid |
$67.15
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
