|
State Supplied - Prevnar13 Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3013471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Prevnar 20 Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6159669
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Prevnar 20 Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6159669
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$886.60 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| 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 |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| 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 |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$354.64
|
| Rate for Payer: NAPHCARE Commercial |
$531.96
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| 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 |
$12.58
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
State Supplied - Prevnar 20 Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6159669
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$1,418.56 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.07
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$1,418.56
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
State Supplied - Rotarix Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Rotarix Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$219.68 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| 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 |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$152.90
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Rotarix Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
3013480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Rotateq Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013481
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$151.90 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$106.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$151.90
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$106.85
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Rotateq Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013481
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Rotateq Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
3013481
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - TDaP Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$167.61 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.78
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$167.61
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$101.62
|
|
|
State Supplied - TDaP Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$104.75 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$41.90
|
| Rate for Payer: Anthem Medicare Advantage |
$41.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.90
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.65
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.90
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$62.85
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$41.90
|
| Rate for Payer: The Alliance Commercial |
$104.75
|
| Rate for Payer: United Healthcare Medicaid |
$51.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.90
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$101.62
|
|
|
State Supplied - TDaP Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3007585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Td Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$169.15 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.91
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$169.15
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$48.95
|
|
|
State Supplied - Td Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Td Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3013452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$105.72 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$42.29
|
| Rate for Payer: Anthem Medicare Advantage |
$42.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$42.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$42.29
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.58
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$42.29
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$63.43
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$42.29
|
| Rate for Payer: The Alliance Commercial |
$105.72
|
| Rate for Payer: United Healthcare Medicaid |
$43.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.29
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$48.95
|
|
|
State Supplied - Varicella Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Varicella Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Varicella Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$246.41 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$246.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$246.41
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
Static or Dynami Afo Pre Ots L4397
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
HCPCS L4397
|
| Hospital Charge Code |
4598606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$64.48 |
| Max. Negotiated Rate |
$857.92 |
| Rate for Payer: Aetna Commercial |
$423.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.27
|
| Rate for Payer: Aetna Managed Medicare |
$131.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.14
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$432.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.06
|
| Rate for Payer: Health EOS Commercial |
$418.37
|
| Rate for Payer: HFN Commercial |
$432.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$352.56
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: NAPHCARE Commercial |
$282.05
|
| Rate for Payer: Preferred Network Access Commercial |
$432.47
|
| Rate for Payer: Quartz Beloit One Network |
$230.34
|
| Rate for Payer: Quartz Commercial |
$305.55
|
| Rate for Payer: Quartz Medicare Advantage |
$282.05
|
| Rate for Payer: The Alliance Commercial |
$857.92
|
| Rate for Payer: WEA Trust Commercial |
$258.54
|
| Rate for Payer: WPS Commercial |
$348.18
|
|
|
Static or Dynami Afo Pre Ots L4397
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
HCPCS L4397
|
| Hospital Charge Code |
4598606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$230.34 |
| Max. Negotiated Rate |
$432.47 |
| Rate for Payer: Aetna Commercial |
$423.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.14
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$432.47
|
| Rate for Payer: Health EOS Commercial |
$418.37
|
| Rate for Payer: HFN Commercial |
$432.47
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: Preferred Network Access Commercial |
$432.47
|
| Rate for Payer: Quartz Beloit One Network |
$230.34
|
| Rate for Payer: Quartz Commercial |
$282.05
|
| Rate for Payer: WEA Trust Commercial |
$258.54
|
| Rate for Payer: WPS Commercial |
$348.18
|
|
|
Static or Dynami Afo Pre Ots L4397
|
Professional
|
Both
|
$452.00
|
|
|
Service Code
|
HCPCS L4397
|
| Hospital Charge Code |
4598606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$206.84 |
| Max. Negotiated Rate |
$618.45 |
| Rate for Payer: Aetna Commercial |
$446.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.27
|
| Rate for Payer: Aetna Managed Medicare |
$214.48
|
| Rate for Payer: Anthem Medicare Advantage |
$214.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$214.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$214.48
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$446.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$214.48
|
| Rate for Payer: Health EOS Commercial |
$427.77
|
| Rate for Payer: HFN Commercial |
$446.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$618.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$618.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: NAPHCARE Commercial |
$321.72
|
| Rate for Payer: Preferred Network Access Commercial |
$446.58
|
| Rate for Payer: Quartz Beloit One Network |
$206.84
|
| Rate for Payer: Quartz Commercial |
$267.95
|
| Rate for Payer: Quartz Medicare Advantage |
$214.48
|
| Rate for Payer: The Alliance Commercial |
$589.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$214.48
|
| Rate for Payer: WEA Trust Commercial |
$258.54
|
| Rate for Payer: WPS Commercial |
$375.34
|
|
|
STATLOCK DIALYSIS CATH DI0120
|
Facility
|
OP
|
$253.00
|
|
| Hospital Charge Code |
4520434
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.67 |
| Max. Negotiated Rate |
$242.07 |
| Rate for Payer: Aetna Commercial |
$236.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.28
|
| Rate for Payer: Aetna Managed Medicare |
$73.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$171.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$126.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.45
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$242.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.25
|
| Rate for Payer: Health EOS Commercial |
$234.18
|
| Rate for Payer: HFN Commercial |
$242.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$197.34
|
| Rate for Payer: Multiplan Commercial |
$210.50
|
| Rate for Payer: NAPHCARE Commercial |
$157.87
|
| Rate for Payer: Preferred Network Access Commercial |
$242.07
|
| Rate for Payer: Quartz Beloit One Network |
$128.93
|
| Rate for Payer: Quartz Commercial |
$171.03
|
| Rate for Payer: Quartz Medicare Advantage |
$157.87
|
| Rate for Payer: The Alliance Commercial |
$131.56
|
| Rate for Payer: WEA Trust Commercial |
$144.72
|
| Rate for Payer: WPS Commercial |
$194.89
|
|
|
STATLOCK DIALYSIS CATH DI0120
|
Facility
|
IP
|
$253.00
|
|
| Hospital Charge Code |
4520434
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$128.93 |
| Max. Negotiated Rate |
$242.07 |
| Rate for Payer: Aetna Commercial |
$236.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.45
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$242.07
|
| Rate for Payer: Health EOS Commercial |
$234.18
|
| Rate for Payer: HFN Commercial |
$242.07
|
| Rate for Payer: Multiplan Commercial |
$210.50
|
| Rate for Payer: Preferred Network Access Commercial |
$242.07
|
| Rate for Payer: Quartz Beloit One Network |
$128.93
|
| Rate for Payer: Quartz Commercial |
$157.87
|
| Rate for Payer: WEA Trust Commercial |
$144.72
|
| Rate for Payer: WPS Commercial |
$194.89
|
|
|
STATLOCK FOLEY CATH DEVICE
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
2963318
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.09 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
