|
Non-State Supplied - MMR Charge
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3013478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.98 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$192.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.55
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$197.10
|
| Rate for Payer: Health EOS Commercial |
$190.67
|
| Rate for Payer: HFN Commercial |
$197.10
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: Preferred Network Access Commercial |
$197.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.98
|
| Rate for Payer: Quartz Commercial |
$128.54
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: WPS Commercial |
$158.68
|
|
|
Non-State Supplied - MMR Charge
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3013478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.99 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$192.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Aetna Managed Medicare |
$59.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$139.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$107.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.55
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$197.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.89
|
| Rate for Payer: Health EOS Commercial |
$190.67
|
| Rate for Payer: HFN Commercial |
$197.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.68
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: NAPHCARE Commercial |
$128.54
|
| Rate for Payer: Preferred Network Access Commercial |
$197.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.98
|
| Rate for Payer: Quartz Commercial |
$139.26
|
| Rate for Payer: Quartz Medicare Advantage |
$128.54
|
| Rate for Payer: The Alliance Commercial |
$107.12
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: WPS Commercial |
$158.68
|
|
|
Non-State Supplied - MMR Charge
|
Professional
|
Both
|
$206.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3013478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.27 |
| Max. Negotiated Rate |
$203.53 |
| Rate for Payer: Aetna Commercial |
$203.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$203.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$101.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.54
|
| Rate for Payer: Health EOS Commercial |
$194.96
|
| Rate for Payer: HFN Commercial |
$203.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$142.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$142.16
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: Preferred Network Access Commercial |
$203.53
|
| Rate for Payer: Quartz Beloit One Network |
$94.27
|
| Rate for Payer: Quartz Commercial |
$122.12
|
| Rate for Payer: The Alliance Commercial |
$107.12
|
| Rate for Payer: United Healthcare Medicaid |
$101.92
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: WPS Commercial |
$158.68
|
|
|
Non-State Supplied - MMR-Varicella Charge
|
Professional
|
Both
|
$387.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3013475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.09 |
| Max. Negotiated Rate |
$424.40 |
| Rate for Payer: Aetna Commercial |
$382.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$346.13
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$382.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$241.49
|
| Rate for Payer: Health EOS Commercial |
$366.26
|
| Rate for Payer: HFN Commercial |
$382.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$424.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$424.40
|
| Rate for Payer: Multiplan Commercial |
$321.98
|
| Rate for Payer: Preferred Network Access Commercial |
$382.36
|
| Rate for Payer: Quartz Beloit One Network |
$177.09
|
| Rate for Payer: Quartz Commercial |
$229.41
|
| Rate for Payer: The Alliance Commercial |
$201.24
|
| Rate for Payer: United Healthcare Medicaid |
$300.74
|
| Rate for Payer: WEA Trust Commercial |
$221.36
|
| Rate for Payer: WPS Commercial |
$298.11
|
|
|
Non-State Supplied - MMR-Varicella Charge
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3013475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.69 |
| Max. Negotiated Rate |
$370.28 |
| Rate for Payer: Aetna Commercial |
$362.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$346.13
|
| Rate for Payer: Aetna Managed Medicare |
$112.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$261.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$201.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$193.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.31
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$370.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$225.23
|
| Rate for Payer: Health EOS Commercial |
$358.21
|
| Rate for Payer: HFN Commercial |
$370.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$301.86
|
| Rate for Payer: Multiplan Commercial |
$321.98
|
| Rate for Payer: NAPHCARE Commercial |
$241.49
|
| Rate for Payer: Preferred Network Access Commercial |
$370.28
|
| Rate for Payer: Quartz Beloit One Network |
$197.22
|
| Rate for Payer: Quartz Commercial |
$261.61
|
| Rate for Payer: Quartz Medicare Advantage |
$241.49
|
| Rate for Payer: The Alliance Commercial |
$201.24
|
| Rate for Payer: WEA Trust Commercial |
$221.36
|
| Rate for Payer: WPS Commercial |
$298.11
|
|
|
Non-State Supplied - MMR-Varicella Charge
|
Facility
|
IP
|
$387.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3013475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.22 |
| Max. Negotiated Rate |
$370.28 |
| Rate for Payer: Aetna Commercial |
$362.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$346.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.31
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$370.28
|
| Rate for Payer: Health EOS Commercial |
$358.21
|
| Rate for Payer: HFN Commercial |
$370.28
|
| Rate for Payer: Multiplan Commercial |
$321.98
|
| Rate for Payer: Preferred Network Access Commercial |
$370.28
|
| Rate for Payer: Quartz Beloit One Network |
$197.22
|
| Rate for Payer: Quartz Commercial |
$241.49
|
| Rate for Payer: WEA Trust Commercial |
$221.36
|
| Rate for Payer: WPS Commercial |
$298.11
|
|
|
Non-State Supplied - Pentacel Charge
|
Professional
|
Both
|
$330.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3513533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.86 |
| Max. Negotiated Rate |
$326.04 |
| Rate for Payer: Aetna Commercial |
$326.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.15
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$326.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$124.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.92
|
| Rate for Payer: Health EOS Commercial |
$312.31
|
| Rate for Payer: HFN Commercial |
$326.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$195.08
|
| Rate for Payer: Multiplan Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$326.04
|
| Rate for Payer: Quartz Beloit One Network |
$151.01
|
| Rate for Payer: Quartz Commercial |
$195.62
|
| Rate for Payer: The Alliance Commercial |
$171.60
|
| Rate for Payer: United Healthcare Medicaid |
$124.86
|
| Rate for Payer: WEA Trust Commercial |
$188.76
|
| Rate for Payer: WPS Commercial |
$254.20
|
|
|
Non-State Supplied - Pentacel Charge
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3513533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.10 |
| Max. Negotiated Rate |
$315.74 |
| Rate for Payer: Aetna Commercial |
$308.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.15
|
| Rate for Payer: Aetna Managed Medicare |
$96.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$223.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$171.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$164.74
|
| 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: Dean Health DHI/DHP/ASO |
$192.06
|
| Rate for Payer: Health EOS Commercial |
$305.45
|
| Rate for Payer: HFN Commercial |
$315.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$257.40
|
| Rate for Payer: Multiplan Commercial |
$274.56
|
| Rate for Payer: NAPHCARE Commercial |
$205.92
|
| Rate for Payer: Preferred Network Access Commercial |
$315.74
|
| Rate for Payer: Quartz Beloit One Network |
$168.17
|
| Rate for Payer: Quartz Commercial |
$223.08
|
| Rate for Payer: Quartz Medicare Advantage |
$205.92
|
| Rate for Payer: The Alliance Commercial |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$188.76
|
| Rate for Payer: WPS Commercial |
$254.20
|
|
|
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
|
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 - 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
|
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 - 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 - 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 - 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
|
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 - 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 - 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 |
$1,418.56 |
| 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 |
$1,418.56
|
| 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 - 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 |
$886.60 |
| Rate for Payer: Aetna Commercial |
$238.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$354.64
|
| Rate for Payer: Anthem Medicare Advantage |
$354.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$354.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$354.64
|
| 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 |
$354.64
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$531.96
|
| 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 |
$354.64
|
| Rate for Payer: The Alliance Commercial |
$886.60
|
| Rate for Payer: United Healthcare Medicaid |
$257.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$354.64
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
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 - 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
|
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 - 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
|
|
