|
Admin All Other - Admin Flu Virus
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5542822
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$259.02 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.64
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$11.70
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$13.50
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
Admin Alteplase/Cathflow 36593
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
5220608
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$20,943.68 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$334.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.56
|
| Rate for Payer: Anthem Medicare Advantage |
$334.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$334.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$334.74
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$334.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$334.74
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,245.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$334.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$334.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$334.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$334.74
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$502.11
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$95.55
|
| Rate for Payer: Quartz Medicare Advantage |
$334.74
|
| Rate for Payer: The Alliance Commercial |
$20,943.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$334.74
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: Wellcare Medicare |
$334.74
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Admin Alteplase/Cathflow 36593
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
5220608
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.03 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$88.20
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Admin Chemo Subq/IM Non-Hormonal Anti-Neoplastic
|
Facility
IP
|
$441.00
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
5220606
|
|
Hospital Revenue Code
|
280
|
| Min. Negotiated Rate |
$216.09 |
| Max. Negotiated Rate |
$405.72 |
| Rate for Payer: Aetna Commercial |
$396.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$233.73
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$405.72
|
| Rate for Payer: Health EOS Commercial |
$392.49
|
| Rate for Payer: HFN Commercial |
$405.72
|
| Rate for Payer: Multiplan Commercial |
$352.80
|
| Rate for Payer: NAPHCARE Commercial |
$264.60
|
| Rate for Payer: Preferred Network Access Commercial |
$405.72
|
| Rate for Payer: Quartz Beloit One Network |
$216.09
|
| Rate for Payer: Quartz Commercial |
$264.60
|
| Rate for Payer: WEA Trust Commercial |
$242.55
|
| Rate for Payer: WPS Commercial |
$326.65
|
|
|
Admin Chemo Subq/IM Non-Hormonal Anti-Neoplastic
|
Facility
OP
|
$441.00
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
5220606
|
|
Hospital Revenue Code
|
280
|
| Min. Negotiated Rate |
$69.63 |
| Max. Negotiated Rate |
$405.72 |
| Rate for Payer: Aetna Commercial |
$396.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$379.26
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$286.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$220.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$211.68
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$233.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$405.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$246.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$392.49
|
| Rate for Payer: HFN Commercial |
$405.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$352.80
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$405.72
|
| Rate for Payer: Quartz Beloit One Network |
$216.09
|
| Rate for Payer: Quartz Commercial |
$286.65
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$330.75
|
| Rate for Payer: WEA Trust Commercial |
$242.55
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$326.65
|
|
|
Admin hepatitis b vaccine G0010
|
Facility
OP
|
$54.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3431532
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$233.12 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.95
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46.95
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$46.95
|
| Rate for Payer: The Alliance Commercial |
$233.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.95
|
| Rate for Payer: United Healthcare PPO |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Admin hepatitis b vaccine G0010
|
Facility
IP
|
$54.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3431532
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Admin hepatitis b vaccine G0010
|
Professional
|
$54.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3431532
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$57.26 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.40
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.26
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Admin influenza virus vac G0008
|
Professional
|
$12.00
|
|
| Hospital Charge Code |
3431533
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Aetna Commercial |
$11.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.32
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.20
|
| Rate for Payer: Health EOS Commercial |
$10.92
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11.40
|
| Rate for Payer: Quartz Beloit One Network |
$5.28
|
| Rate for Payer: Quartz Commercial |
$6.84
|
| Rate for Payer: The Alliance Commercial |
$6.00
|
| Rate for Payer: WEA Trust Commercial |
$6.60
|
| Rate for Payer: WPS Commercial |
$8.89
|
|
|
Admin influenza virus vac G0008
|
Facility
IP
|
$12.00
|
|
| Hospital Charge Code |
3431533
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$11.04 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.36
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.04
|
| Rate for Payer: Health EOS Commercial |
$10.68
|
| Rate for Payer: HFN Commercial |
$11.04
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11.04
|
| Rate for Payer: Quartz Beloit One Network |
$5.88
|
| Rate for Payer: Quartz Commercial |
$7.20
|
| Rate for Payer: WEA Trust Commercial |
$6.60
|
| Rate for Payer: WPS Commercial |
$8.89
|
|
|
Admin influenza virus vac G0008
|
Facility
OP
|
$12.00
|
|
| Hospital Charge Code |
3431533
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.32
|
| Rate for Payer: Aetna Managed Medicare |
$3.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.36
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.72
|
| Rate for Payer: Health EOS Commercial |
$10.68
|
| Rate for Payer: HFN Commercial |
$11.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11.04
|
| Rate for Payer: Quartz Beloit One Network |
$5.88
|
| Rate for Payer: Quartz Commercial |
$7.80
|
| Rate for Payer: Quartz Medicare Advantage |
$7.20
|
| Rate for Payer: The Alliance Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$6.60
|
| Rate for Payer: WPS Commercial |
$8.89
|
|
|
Admin Influenze Medicare
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT G0008
|
| Hospital Charge Code |
3970751
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$174.65 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.95
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46.95
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$46.95
|
| Rate for Payer: The Alliance Commercial |
$7.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.95
|
| Rate for Payer: United Healthcare PPO |
$16.50
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
Admin Influenze Medicare
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT G0008
|
| Hospital Charge Code |
3970751
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
Administered - Dtap-Hep B-IPV Charge
|
Professional
|
$220.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3013472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna Commercial |
$209.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$209.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$110.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.00
|
| Rate for Payer: Health EOS Commercial |
$200.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$179.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.49
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: Preferred Network Access Commercial |
$209.00
|
| Rate for Payer: Quartz Beloit One Network |
$96.80
|
| Rate for Payer: Quartz Commercial |
$125.40
|
| Rate for Payer: The Alliance Commercial |
$110.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
Administered - Dtap-Hep B-IPV Charge
|
Facility
OP
|
$220.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3013472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$880.00 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Aetna Managed Medicare |
$61.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$105.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.11
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$165.00
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$143.00
|
| Rate for Payer: Quartz Medicare Advantage |
$132.00
|
| Rate for Payer: The Alliance Commercial |
$880.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
Administered - Dtap-Hep B-IPV Charge
|
Facility
IP
|
$220.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3013472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$202.40 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
Administered - Hep A Adult Charge
|
Professional
|
$194.00
|
|
|
Service Code
|
CPT 90632
|
| Hospital Charge Code |
3013461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.54 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna Commercial |
$184.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$71.85
|
| Rate for Payer: Anthem Medicare Advantage |
$71.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$71.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$71.85
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$184.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$97.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.54
|
| Rate for Payer: Health EOS Commercial |
$176.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$85.79
|
| Rate for Payer: Independent Care Health Plan Medicare |
$71.85
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: Preferred Network Access Commercial |
$184.30
|
| Rate for Payer: Quartz Beloit One Network |
$85.36
|
| Rate for Payer: Quartz Commercial |
$110.58
|
| Rate for Payer: Quartz Medicare Advantage |
$71.85
|
| Rate for Payer: The Alliance Commercial |
$179.63
|
| Rate for Payer: United Healthcare Medicaid |
$94.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.85
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$176.35
|
|
|
Administered - Hep A Adult Charge
|
Facility
OP
|
$194.00
|
|
|
Service Code
|
CPT 90632
|
| Hospital Charge Code |
3013461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.33
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.50
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$176.35
|
|
|
Administered - Hep A Adult Charge
|
Facility
IP
|
$194.00
|
|
|
Service Code
|
CPT 90632
|
| Hospital Charge Code |
3013461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
Administered - Hep A/B Charge
|
Facility
OP
|
$281.00
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
3013465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.68 |
| Max. Negotiated Rate |
$258.52 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.66
|
| Rate for Payer: Aetna Managed Medicare |
$78.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$182.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$140.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$134.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.93
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$258.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.25
|
| Rate for Payer: Health EOS Commercial |
$250.09
|
| Rate for Payer: HFN Commercial |
$258.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.75
|
| Rate for Payer: Multiplan Commercial |
$224.80
|
| Rate for Payer: NAPHCARE Commercial |
$168.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.52
|
| Rate for Payer: Quartz Beloit One Network |
$137.69
|
| Rate for Payer: Quartz Commercial |
$182.65
|
| Rate for Payer: Quartz Medicare Advantage |
$168.60
|
| Rate for Payer: WEA Trust Commercial |
$154.55
|
| Rate for Payer: WPS Commercial |
$208.14
|
|
|
Administered - Hep A/B Charge
|
Facility
IP
|
$281.00
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
3013465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.69 |
| Max. Negotiated Rate |
$258.52 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.93
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$258.52
|
| Rate for Payer: Health EOS Commercial |
$250.09
|
| Rate for Payer: HFN Commercial |
$258.52
|
| Rate for Payer: Multiplan Commercial |
$224.80
|
| Rate for Payer: NAPHCARE Commercial |
$168.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.52
|
| Rate for Payer: Quartz Beloit One Network |
$137.69
|
| Rate for Payer: Quartz Commercial |
$168.60
|
| Rate for Payer: WEA Trust Commercial |
$154.55
|
| Rate for Payer: WPS Commercial |
$208.14
|
|
|
Administered - Hep A/B Charge
|
Professional
|
$281.00
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
3013465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.64 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$266.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.66
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$140.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.60
|
| Rate for Payer: Health EOS Commercial |
$255.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$186.59
|
| Rate for Payer: Multiplan Commercial |
$224.80
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$123.64
|
| Rate for Payer: Quartz Commercial |
$160.17
|
| Rate for Payer: The Alliance Commercial |
$140.50
|
| Rate for Payer: United Healthcare Medicaid |
$136.40
|
| Rate for Payer: WEA Trust Commercial |
$154.55
|
| Rate for Payer: WPS Commercial |
$208.14
|
|
|
Administered - Hep B Adult Charge
|
Facility
OP
|
$148.00
|
|
|
Service Code
|
CPT 90746
|
| Hospital Charge Code |
3013464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$175.94 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Aetna Managed Medicare |
$41.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.11
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.00
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$96.20
|
| Rate for Payer: Quartz Medicare Advantage |
$88.80
|
| Rate for Payer: The Alliance Commercial |
$51.80
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$175.94
|
|
|
Administered - Hep B Adult Charge
|
Facility
IP
|
$148.00
|
|
|
Service Code
|
CPT 90746
|
| Hospital Charge Code |
3013464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.52 |
| Max. Negotiated Rate |
$136.16 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$88.80
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
Administered - Hep B Adult Charge
|
Professional
|
$148.00
|
|
|
Service Code
|
CPT 90746
|
| Hospital Charge Code |
3013464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.12 |
| Max. Negotiated Rate |
$175.94 |
| Rate for Payer: Aetna Commercial |
$140.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Aetna Managed Medicare |
$70.38
|
| Rate for Payer: Anthem Medicare Advantage |
$70.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$70.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$70.38
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$140.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.38
|
| Rate for Payer: Health EOS Commercial |
$134.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$101.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$70.38
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: Preferred Network Access Commercial |
$140.60
|
| Rate for Payer: Quartz Beloit One Network |
$65.12
|
| Rate for Payer: Quartz Commercial |
$84.36
|
| Rate for Payer: Quartz Medicare Advantage |
$70.38
|
| Rate for Payer: The Alliance Commercial |
$175.94
|
| Rate for Payer: United Healthcare Medicaid |
$81.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.38
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$175.94
|
|
