|
Serotype 19
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 19
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 23
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943008
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 23
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943008
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 23
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943008
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 26
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943009
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 26
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943009
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 26
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943009
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 3
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943000
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 3
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943000
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 3
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943000
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 4
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 4
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 4
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 5
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 5
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 5
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 51
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943010
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 51
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943010
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 51
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943010
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 56
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943011
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 56
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943011
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 56
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943011
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 68
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 68
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
