|
Administered - Hep A/B Charge
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
3013465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.20 |
| Max. Negotiated Rate |
$268.86 |
| Rate for Payer: Aetna Commercial |
$263.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.89
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$268.86
|
| Rate for Payer: Health EOS Commercial |
$260.09
|
| Rate for Payer: HFN Commercial |
$268.86
|
| Rate for Payer: Multiplan Commercial |
$233.79
|
| Rate for Payer: Preferred Network Access Commercial |
$268.86
|
| Rate for Payer: Quartz Beloit One Network |
$143.20
|
| Rate for Payer: Quartz Commercial |
$175.34
|
| Rate for Payer: WEA Trust Commercial |
$160.73
|
| Rate for Payer: WPS Commercial |
$216.45
|
|
|
Administered - Hep B Adult Charge
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 90746
|
| Hospital Charge Code |
3013464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.42 |
| Max. Negotiated Rate |
$141.61 |
| Rate for Payer: Aetna Commercial |
$138.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Health EOS Commercial |
$136.99
|
| Rate for Payer: HFN Commercial |
$141.61
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: Preferred Network Access Commercial |
$141.61
|
| Rate for Payer: Quartz Beloit One Network |
$75.42
|
| Rate for Payer: Quartz Commercial |
$92.35
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$114.00
|
|
|
Administered - Hep B Adult Charge
|
Professional
|
Both
|
$148.00
|
|
|
Service Code
|
CPT 90746
|
| Hospital Charge Code |
3013464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.72 |
| Max. Negotiated Rate |
$195.39 |
| Rate for Payer: Aetna Commercial |
$146.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Aetna Managed Medicare |
$78.16
|
| Rate for Payer: Anthem Medicare Advantage |
$78.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$78.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$78.16
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$146.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.19
|
| Rate for Payer: Health EOS Commercial |
$140.07
|
| Rate for Payer: HFN Commercial |
$146.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$105.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$78.16
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: NAPHCARE Commercial |
$117.23
|
| Rate for Payer: Preferred Network Access Commercial |
$146.22
|
| Rate for Payer: Quartz Beloit One Network |
$67.72
|
| Rate for Payer: Quartz Commercial |
$87.73
|
| Rate for Payer: Quartz Medicare Advantage |
$78.16
|
| Rate for Payer: The Alliance Commercial |
$195.39
|
| Rate for Payer: United Healthcare Medicaid |
$75.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.16
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$182.98
|
|
|
Administered - Hep B Adult Charge
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
CPT 90746
|
| Hospital Charge Code |
3013464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.10 |
| Max. Negotiated Rate |
$312.62 |
| Rate for Payer: Aetna Commercial |
$138.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Aetna Managed Medicare |
$43.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.83
|
| Rate for Payer: Health EOS Commercial |
$136.99
|
| Rate for Payer: HFN Commercial |
$141.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.44
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: NAPHCARE Commercial |
$92.35
|
| Rate for Payer: Preferred Network Access Commercial |
$141.61
|
| Rate for Payer: Quartz Beloit One Network |
$75.42
|
| Rate for Payer: Quartz Commercial |
$100.05
|
| Rate for Payer: Quartz Medicare Advantage |
$92.35
|
| Rate for Payer: The Alliance Commercial |
$312.62
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$182.98
|
|
|
Administered - Metoclopramide Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
3983494
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.43
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$4.49
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$2.70
|
|
|
Administered - Metoclopramide Charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
3983494
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$1.12
|
| Rate for Payer: Anthem Medicare Advantage |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.12
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.08
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$1.68
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1.12
|
| Rate for Payer: The Alliance Commercial |
$3.09
|
| Rate for Payer: United Healthcare Medicaid |
$1.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.12
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$2.70
|
|
|
Administered - Metoclopramide Charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
3983494
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Administered - Rabies Charge
|
Facility
|
OP
|
$643.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3013491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$320.99 |
| Max. Negotiated Rate |
$1,330.16 |
| Rate for Payer: Aetna Commercial |
$601.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.10
|
| Rate for Payer: Aetna Managed Medicare |
$332.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$434.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$334.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$320.99
|
| Rate for Payer: Anthem Medicare Advantage |
$332.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$332.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$332.54
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$615.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$332.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$444.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$332.54
|
| Rate for Payer: Health EOS Commercial |
$595.16
|
| Rate for Payer: HFN Commercial |
$615.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,237.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$332.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$332.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$332.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$332.54
|
| Rate for Payer: Multiplan Commercial |
$534.98
|
| Rate for Payer: NAPHCARE Commercial |
$498.81
|
| Rate for Payer: Preferred Network Access Commercial |
$615.22
|
| Rate for Payer: Quartz Beloit One Network |
$327.67
|
| Rate for Payer: Quartz Commercial |
$434.67
|
| Rate for Payer: Quartz Medicare Advantage |
$332.54
|
| Rate for Payer: The Alliance Commercial |
$1,330.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$332.54
|
| Rate for Payer: WEA Trust Commercial |
$367.80
|
| Rate for Payer: Wellcare Medicare |
$332.54
|
| Rate for Payer: WPS Commercial |
$839.19
|
|
|
Administered - Rabies Charge
|
Professional
|
Both
|
$643.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3013491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$294.24 |
| Max. Negotiated Rate |
$839.19 |
| Rate for Payer: Aetna Commercial |
$635.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.10
|
| Rate for Payer: Aetna Managed Medicare |
$332.54
|
| Rate for Payer: Anthem Medicare Advantage |
$332.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$332.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$332.54
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$635.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$326.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$335.68
|
| Rate for Payer: Health EOS Commercial |
$608.54
|
| Rate for Payer: HFN Commercial |
$635.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$527.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$527.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$332.54
|
| Rate for Payer: Multiplan Commercial |
$534.98
|
| Rate for Payer: NAPHCARE Commercial |
$498.81
|
| Rate for Payer: Preferred Network Access Commercial |
$635.28
|
| Rate for Payer: Quartz Beloit One Network |
$294.24
|
| Rate for Payer: Quartz Commercial |
$381.17
|
| Rate for Payer: Quartz Medicare Advantage |
$332.54
|
| Rate for Payer: The Alliance Commercial |
$831.35
|
| Rate for Payer: United Healthcare Medicaid |
$326.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$332.54
|
| Rate for Payer: WEA Trust Commercial |
$367.80
|
| Rate for Payer: WPS Commercial |
$839.19
|
|
|
Administered - Rabies Charge
|
Facility
|
IP
|
$643.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3013491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$327.67 |
| Max. Negotiated Rate |
$615.22 |
| Rate for Payer: Aetna Commercial |
$601.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.42
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$615.22
|
| Rate for Payer: Health EOS Commercial |
$595.16
|
| Rate for Payer: HFN Commercial |
$615.22
|
| Rate for Payer: Multiplan Commercial |
$534.98
|
| Rate for Payer: Preferred Network Access Commercial |
$615.22
|
| Rate for Payer: Quartz Beloit One Network |
$327.67
|
| Rate for Payer: Quartz Commercial |
$401.23
|
| Rate for Payer: WEA Trust Commercial |
$367.80
|
| Rate for Payer: WPS Commercial |
$495.30
|
|
|
Administered - Shingrix Charge
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5394637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.58 |
| Max. Negotiated Rate |
$335.92 |
| Rate for Payer: Aetna Commercial |
$335.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$335.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$224.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$212.16
|
| Rate for Payer: Health EOS Commercial |
$321.78
|
| Rate for Payer: HFN Commercial |
$335.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$252.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$252.15
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: Preferred Network Access Commercial |
$335.92
|
| Rate for Payer: Quartz Beloit One Network |
$155.58
|
| Rate for Payer: Quartz Commercial |
$201.55
|
| Rate for Payer: The Alliance Commercial |
$176.80
|
| Rate for Payer: United Healthcare Medicaid |
$224.13
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Administered - Shingrix Charge
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5394637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.01 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna Commercial |
$318.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Aetna Managed Medicare |
$99.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$229.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$176.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.41
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$325.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.88
|
| Rate for Payer: Health EOS Commercial |
$314.70
|
| Rate for Payer: HFN Commercial |
$325.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.20
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: NAPHCARE Commercial |
$212.16
|
| Rate for Payer: Preferred Network Access Commercial |
$325.31
|
| Rate for Payer: Quartz Beloit One Network |
$173.26
|
| Rate for Payer: Quartz Commercial |
$229.84
|
| Rate for Payer: Quartz Medicare Advantage |
$212.16
|
| Rate for Payer: The Alliance Commercial |
$176.80
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Administered - Shingrix Charge
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5394637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.26 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna Commercial |
$318.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.41
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$325.31
|
| Rate for Payer: Health EOS Commercial |
$314.70
|
| Rate for Payer: HFN Commercial |
$325.31
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: Preferred Network Access Commercial |
$325.31
|
| Rate for Payer: Quartz Beloit One Network |
$173.26
|
| Rate for Payer: Quartz Commercial |
$212.16
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Administered - Typhoid Charge
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
CPT 90691
|
| Hospital Charge Code |
3013492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.77 |
| Max. Negotiated Rate |
$191.67 |
| Rate for Payer: Aetna Commercial |
$191.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$191.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$101.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.06
|
| Rate for Payer: Health EOS Commercial |
$183.60
|
| Rate for Payer: HFN Commercial |
$191.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.79
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: Preferred Network Access Commercial |
$191.67
|
| Rate for Payer: Quartz Beloit One Network |
$88.77
|
| Rate for Payer: Quartz Commercial |
$115.00
|
| Rate for Payer: The Alliance Commercial |
$100.88
|
| Rate for Payer: United Healthcare Medicaid |
$101.78
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
Administered - Typhoid Charge
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 90691
|
| Hospital Charge Code |
3013492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.86 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$121.06
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
Administered - Typhoid Charge
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 90691
|
| Hospital Charge Code |
3013492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.49 |
| Max. Negotiated Rate |
$185.62 |
| Rate for Payer: Aetna Commercial |
$181.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Aetna Managed Medicare |
$56.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.93
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.91
|
| Rate for Payer: Health EOS Commercial |
$179.57
|
| Rate for Payer: HFN Commercial |
$185.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.32
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$121.06
|
| Rate for Payer: Preferred Network Access Commercial |
$185.62
|
| Rate for Payer: Quartz Beloit One Network |
$98.86
|
| Rate for Payer: Quartz Commercial |
$131.14
|
| Rate for Payer: Quartz Medicare Advantage |
$121.06
|
| Rate for Payer: The Alliance Commercial |
$100.88
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$149.44
|
|
|
Administered - Zostavax Charge
|
Facility
|
OP
|
$484.00
|
|
|
Service Code
|
CPT 90736
|
| Hospital Charge Code |
3013483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.94 |
| Max. Negotiated Rate |
$463.09 |
| Rate for Payer: Aetna Commercial |
$453.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.89
|
| Rate for Payer: Aetna Managed Medicare |
$140.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$327.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$251.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$241.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$266.78
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$463.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$281.69
|
| Rate for Payer: Health EOS Commercial |
$447.99
|
| Rate for Payer: HFN Commercial |
$463.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.52
|
| Rate for Payer: Multiplan Commercial |
$402.69
|
| Rate for Payer: NAPHCARE Commercial |
$302.02
|
| Rate for Payer: Preferred Network Access Commercial |
$463.09
|
| Rate for Payer: Quartz Beloit One Network |
$246.65
|
| Rate for Payer: Quartz Commercial |
$327.18
|
| Rate for Payer: Quartz Medicare Advantage |
$302.02
|
| Rate for Payer: The Alliance Commercial |
$251.68
|
| Rate for Payer: WEA Trust Commercial |
$276.85
|
| Rate for Payer: WPS Commercial |
$372.83
|
|
|
Administered - Zostavax Charge
|
Facility
|
IP
|
$484.00
|
|
|
Service Code
|
CPT 90736
|
| Hospital Charge Code |
3013483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$246.65 |
| Max. Negotiated Rate |
$463.09 |
| Rate for Payer: Aetna Commercial |
$453.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$266.78
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$463.09
|
| Rate for Payer: Health EOS Commercial |
$447.99
|
| Rate for Payer: HFN Commercial |
$463.09
|
| Rate for Payer: Multiplan Commercial |
$402.69
|
| Rate for Payer: Preferred Network Access Commercial |
$463.09
|
| Rate for Payer: Quartz Beloit One Network |
$246.65
|
| Rate for Payer: Quartz Commercial |
$302.02
|
| Rate for Payer: WEA Trust Commercial |
$276.85
|
| Rate for Payer: WPS Commercial |
$372.83
|
|
|
Administered - Zostavax Charge
|
Professional
|
Both
|
$484.00
|
|
|
Service Code
|
CPT 90736
|
| Hospital Charge Code |
3013483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$221.48 |
| Max. Negotiated Rate |
$478.19 |
| Rate for Payer: Aetna Commercial |
$478.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.89
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$478.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$251.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$302.02
|
| Rate for Payer: Health EOS Commercial |
$458.06
|
| Rate for Payer: HFN Commercial |
$478.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$368.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$368.12
|
| Rate for Payer: Multiplan Commercial |
$402.69
|
| Rate for Payer: Preferred Network Access Commercial |
$478.19
|
| Rate for Payer: Quartz Beloit One Network |
$221.48
|
| Rate for Payer: Quartz Commercial |
$286.92
|
| Rate for Payer: The Alliance Commercial |
$251.68
|
| Rate for Payer: WEA Trust Commercial |
$276.85
|
| Rate for Payer: WPS Commercial |
$372.83
|
|
|
Admin pneumococcal vaccine G0009
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3408191
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.96 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Admin pneumococcal vaccine G0009
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3408191
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$24.71 |
| Max. Negotiated Rate |
$59.55 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.70
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.55
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: The Alliance Commercial |
$28.08
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Admin pneumococcal vaccine G0009
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3408191
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Admin Pneumo Vaccine (Per Dialysis Com Ins)
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5622232
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$49.75 |
| Rate for Payer: Aetna Commercial |
$48.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.66
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$49.75
|
| Rate for Payer: Health EOS Commercial |
$48.13
|
| Rate for Payer: HFN Commercial |
$49.75
|
| Rate for Payer: Multiplan Commercial |
$43.26
|
| Rate for Payer: Preferred Network Access Commercial |
$49.75
|
| Rate for Payer: Quartz Beloit One Network |
$26.50
|
| Rate for Payer: Quartz Commercial |
$32.45
|
| Rate for Payer: WEA Trust Commercial |
$29.74
|
| Rate for Payer: WPS Commercial |
$40.06
|
|
|
Admin Pneumo Vaccine (Per Dialysis Com Ins)
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5622232
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.96 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$48.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.51
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.96
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$49.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$48.13
|
| Rate for Payer: HFN Commercial |
$49.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$43.26
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$49.75
|
| Rate for Payer: Quartz Beloit One Network |
$26.50
|
| Rate for Payer: Quartz Commercial |
$35.15
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$40.56
|
| Rate for Payer: WEA Trust Commercial |
$29.74
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$40.06
|
|
|
Admin Pneumo Vaccine (Per Dialysis Medicare/MADV)
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
5622233
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.96 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$48.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.51
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.96
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$49.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$48.13
|
| Rate for Payer: HFN Commercial |
$49.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$43.26
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$49.75
|
| Rate for Payer: Quartz Beloit One Network |
$26.50
|
| Rate for Payer: Quartz Commercial |
$35.15
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$40.56
|
| Rate for Payer: WEA Trust Commercial |
$29.74
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$40.06
|
|
