|
DRVVT Screen
|
Facility
IP
|
$167.00
|
|
|
Service Code
|
CPT 85613
|
| Hospital Charge Code |
2942943
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$81.83 |
| Max. Negotiated Rate |
$153.64 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$100.20
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
DRVVT Screen
|
Professional
|
$167.00
|
|
|
Service Code
|
CPT 85613
|
| Hospital Charge Code |
2942943
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.58 |
| Max. Negotiated Rate |
$158.65 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Aetna Managed Medicare |
$9.58
|
| Rate for Payer: Anthem Medicare Advantage |
$9.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.58
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.58
|
| Rate for Payer: Health EOS Commercial |
$151.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.58
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: Preferred Network Access Commercial |
$158.65
|
| Rate for Payer: Quartz Beloit One Network |
$73.48
|
| Rate for Payer: Quartz Commercial |
$95.19
|
| Rate for Payer: Quartz Medicare Advantage |
$9.58
|
| Rate for Payer: The Alliance Commercial |
$37.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.58
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$42.15
|
|
|
dRVVT Screen w/ Reflex dRVVT Confirm & dRVVT 1:1 Mix
|
Professional
|
$25.00
|
|
|
Service Code
|
CPT 85613
|
| Hospital Charge Code |
4076153
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.58 |
| Max. Negotiated Rate |
$42.15 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Aetna Managed Medicare |
$9.58
|
| Rate for Payer: Anthem Medicare Advantage |
$9.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.58
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.58
|
| Rate for Payer: Health EOS Commercial |
$22.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.58
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.75
|
| Rate for Payer: Quartz Beloit One Network |
$11.00
|
| Rate for Payer: Quartz Commercial |
$14.25
|
| Rate for Payer: Quartz Medicare Advantage |
$9.58
|
| Rate for Payer: The Alliance Commercial |
$37.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.58
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$42.15
|
|
|
dRVVT Screen w/ Reflex dRVVT Confirm & dRVVT 1:1 Mix
|
Facility
IP
|
$25.00
|
|
|
Service Code
|
CPT 85613
|
| Hospital Charge Code |
4076153
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
dRVVT Screen w/ Reflex dRVVT Confirm & dRVVT 1:1 Mix
|
Facility
OP
|
$25.00
|
|
|
Service Code
|
CPT 85613
|
| Hospital Charge Code |
4076153
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.58 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Aetna Managed Medicare |
$9.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.90
|
| Rate for Payer: Anthem Medicaid |
$9.90
|
| Rate for Payer: Anthem Medicare Advantage |
$9.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.58
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.90
|
| Rate for Payer: Dean Health Medicaid |
$9.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.58
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.58
|
| Rate for Payer: Managed Health Services Medicaid |
$10.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.58
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$14.37
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.90
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$16.25
|
| Rate for Payer: Quartz Medicare Advantage |
$9.58
|
| Rate for Payer: The Alliance Commercial |
$100.00
|
| Rate for Payer: United Healthcare Medicaid |
$9.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.58
|
| Rate for Payer: United Healthcare PPO |
$18.75
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: Wellcare Medicare |
$9.58
|
| Rate for Payer: WMAP Medicaid |
$9.90
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
dsDNA to TheraTest
|
Professional
|
$54.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
2798805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$60.46 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$13.74
|
| Rate for Payer: Anthem Medicare Advantage |
$13.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.74
|
| 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 |
$13.74
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.74
|
| 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: Quartz Medicare Advantage |
$13.74
|
| Rate for Payer: The Alliance Commercial |
$54.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.74
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$60.46
|
|
|
dsDNA to TheraTest
|
Facility
IP
|
$54.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
2798805
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
dsDNA to TheraTest
|
Facility
OP
|
$54.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
2798805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$13.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.81
|
| Rate for Payer: Anthem Medicaid |
$14.20
|
| Rate for Payer: Anthem Medicare Advantage |
$13.74
|
| 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 |
$13.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.74
|
| 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 |
$13.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.20
|
| Rate for Payer: Dean Health Medicaid |
$14.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.74
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.74
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.74
|
| Rate for Payer: Managed Health Services Medicaid |
$14.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.74
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.61
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.20
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$13.74
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.74
|
| Rate for Payer: United Healthcare PPO |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: Wellcare Medicare |
$13.74
|
| Rate for Payer: WMAP Medicaid |
$14.20
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
DTAP-HEP B-IPV Vaccine, IM 90723
|
Professional
|
$213.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3397515
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$202.35 |
| Rate for Payer: Quartz Commercial |
$121.41
|
| Rate for Payer: Aetna Commercial |
$202.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.18
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$202.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$106.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.80
|
| Rate for Payer: Health EOS Commercial |
$193.83
|
| 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 |
$170.40
|
| Rate for Payer: Preferred Network Access Commercial |
$202.35
|
| Rate for Payer: Quartz Beloit One Network |
$93.72
|
| Rate for Payer: The Alliance Commercial |
$106.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$117.15
|
| Rate for Payer: WPS Commercial |
$157.77
|
|
|
DTAP-HEP B-IPV Vaccine, IM 90723
|
Facility
OP
|
$213.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3397515
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.64 |
| Max. Negotiated Rate |
$852.00 |
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.18
|
| Rate for Payer: Aetna Managed Medicare |
$59.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$138.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.89
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$195.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.19
|
| Rate for Payer: Health EOS Commercial |
$189.57
|
| Rate for Payer: HFN Commercial |
$195.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.75
|
| Rate for Payer: Multiplan Commercial |
$170.40
|
| Rate for Payer: NAPHCARE Commercial |
$127.80
|
| Rate for Payer: Preferred Network Access Commercial |
$195.96
|
| Rate for Payer: Quartz Beloit One Network |
$104.37
|
| Rate for Payer: Quartz Commercial |
$138.45
|
| Rate for Payer: Quartz Medicare Advantage |
$127.80
|
| Rate for Payer: The Alliance Commercial |
$852.00
|
| Rate for Payer: WEA Trust Commercial |
$117.15
|
| Rate for Payer: WPS Commercial |
$157.77
|
|
|
DTAP-HEP B-IPV Vaccine, IM 90723
|
Facility
IP
|
$213.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3397515
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.37 |
| Max. Negotiated Rate |
$195.96 |
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.89
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$195.96
|
| Rate for Payer: Health EOS Commercial |
$189.57
|
| Rate for Payer: HFN Commercial |
$195.96
|
| Rate for Payer: Multiplan Commercial |
$170.40
|
| Rate for Payer: NAPHCARE Commercial |
$127.80
|
| Rate for Payer: Preferred Network Access Commercial |
$195.96
|
| Rate for Payer: Quartz Beloit One Network |
$104.37
|
| Rate for Payer: Quartz Commercial |
$127.80
|
| Rate for Payer: WEA Trust Commercial |
$117.15
|
| Rate for Payer: WPS Commercial |
$157.77
|
|
|
DTAP-HEP B-IPV Vaccine, IM 90723 VFC Charge
|
Facility
OP
|
$20.83
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
5466787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$83.32 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
DTAP-HEP B-IPV Vaccine, IM 90723 VFC Charge
|
Professional
|
$20.83
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
5466787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$179.49 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| 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 |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
DTAP-HEP B-IPV Vaccine, IM 90723 VFC Charge
|
Facility
IP
|
$20.83
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
5466787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
DTAP-HIB-IP Vaccine, IM 90698
|
Professional
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3376930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$270.75 |
| Rate for Payer: Aetna Commercial |
$270.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$270.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$142.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.00
|
| Rate for Payer: Health EOS Commercial |
$259.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.58
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$270.75
|
| Rate for Payer: Quartz Beloit One Network |
$125.40
|
| Rate for Payer: Quartz Commercial |
$162.45
|
| Rate for Payer: The Alliance Commercial |
$142.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
DTAP-HIB-IP Vaccine, IM 90698
|
Facility
IP
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3376930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
DTAP-HIB-IP Vaccine, IM 90698
|
Facility
OP
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3376930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696
|
Facility
IP
|
$166.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3455576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.34 |
| Max. Negotiated Rate |
$152.72 |
| Rate for Payer: Aetna Commercial |
$149.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.98
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: Health EOS Commercial |
$147.74
|
| Rate for Payer: HFN Commercial |
$152.72
|
| Rate for Payer: Multiplan Commercial |
$132.80
|
| Rate for Payer: NAPHCARE Commercial |
$99.60
|
| Rate for Payer: Preferred Network Access Commercial |
$152.72
|
| Rate for Payer: Quartz Beloit One Network |
$81.34
|
| Rate for Payer: Quartz Commercial |
$99.60
|
| Rate for Payer: WEA Trust Commercial |
$91.30
|
| Rate for Payer: WPS Commercial |
$122.96
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696
|
Professional
|
$166.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3455576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$157.70 |
| Rate for Payer: Aetna Commercial |
$157.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.76
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$157.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.60
|
| Rate for Payer: Health EOS Commercial |
$151.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.84
|
| Rate for Payer: Multiplan Commercial |
$132.80
|
| Rate for Payer: Preferred Network Access Commercial |
$157.70
|
| Rate for Payer: Quartz Beloit One Network |
$73.04
|
| Rate for Payer: Quartz Commercial |
$94.62
|
| Rate for Payer: The Alliance Commercial |
$83.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$91.30
|
| Rate for Payer: WPS Commercial |
$122.96
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696
|
Facility
OP
|
$166.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3455576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.48 |
| Max. Negotiated Rate |
$152.72 |
| Rate for Payer: Aetna Commercial |
$149.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.76
|
| Rate for Payer: Aetna Managed Medicare |
$46.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$107.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.98
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.89
|
| Rate for Payer: Health EOS Commercial |
$147.74
|
| Rate for Payer: HFN Commercial |
$152.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.50
|
| Rate for Payer: Multiplan Commercial |
$132.80
|
| Rate for Payer: NAPHCARE Commercial |
$99.60
|
| Rate for Payer: Preferred Network Access Commercial |
$152.72
|
| Rate for Payer: Quartz Beloit One Network |
$81.34
|
| Rate for Payer: Quartz Commercial |
$107.90
|
| Rate for Payer: Quartz Medicare Advantage |
$99.60
|
| Rate for Payer: WEA Trust Commercial |
$91.30
|
| Rate for Payer: WPS Commercial |
$122.96
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696 VFC Charge
|
Facility
IP
|
$20.83
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
5084633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696 VFC Charge
|
Facility
OP
|
$20.83
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
5084633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696 VFC Charge
|
Professional
|
$20.83
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
5084633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$107.84 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.84
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
DTAP Vaccine, <7 Yrs, IM 90700
|
Professional
|
$105.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3455573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.00
|
| Rate for Payer: Health EOS Commercial |
$95.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.16
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$99.75
|
| Rate for Payer: Quartz Beloit One Network |
$46.20
|
| Rate for Payer: Quartz Commercial |
$59.85
|
| Rate for Payer: The Alliance Commercial |
$52.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
DTAP Vaccine, <7 Yrs, IM 90700
|
Facility
OP
|
$105.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3455573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$29.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
