|
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 |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
dRVVT Screen w/ Reflex dRVVT Confirm & dRVVT 1:1 Mix
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
CPT 85613
|
| Hospital Charge Code |
4076153
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$43.84 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$9.96
|
| Rate for Payer: Anthem Medicare Advantage |
$9.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.96
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.96
|
| Rate for Payer: Health EOS Commercial |
$23.66
|
| Rate for Payer: HFN Commercial |
$24.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.96
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$14.94
|
| Rate for Payer: Preferred Network Access Commercial |
$24.70
|
| Rate for Payer: Quartz Beloit One Network |
$11.44
|
| Rate for Payer: Quartz Commercial |
$14.82
|
| Rate for Payer: Quartz Medicare Advantage |
$9.96
|
| Rate for Payer: The Alliance Commercial |
$39.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.96
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$43.84
|
|
|
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 |
$9.96 |
| Max. Negotiated Rate |
$39.85 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$9.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.54
|
| Rate for Payer: Anthem Medicare Advantage |
$9.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.96
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.96
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.96
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$14.94
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$9.96
|
| Rate for Payer: The Alliance Commercial |
$39.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.96
|
| Rate for Payer: United Healthcare PPO |
$19.50
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: Wellcare Medicare |
$9.96
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
dsDNA to TheraTest
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
2798805
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
dsDNA to TheraTest
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
2798805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$62.87 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$14.29
|
| Rate for Payer: Anthem Medicare Advantage |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.29
|
| 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 |
$14.29
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.29
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$21.43
|
| 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: Quartz Medicare Advantage |
$14.29
|
| Rate for Payer: The Alliance Commercial |
$56.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.29
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$62.87
|
|
|
dsDNA to TheraTest
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
2798805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$57.16 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$14.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.72
|
| Rate for Payer: Anthem Medicare Advantage |
$14.29
|
| 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 |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.29
|
| 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 |
$14.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.29
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.29
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$21.43
|
| 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 |
$14.29
|
| Rate for Payer: The Alliance Commercial |
$57.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.29
|
| Rate for Payer: United Healthcare PPO |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: Wellcare Medicare |
$14.29
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
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 |
$108.54 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$132.91
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
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 |
$62.03 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$62.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.97
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.14
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$132.91
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$143.99
|
| Rate for Payer: Quartz Medicare Advantage |
$132.91
|
| Rate for Payer: The Alliance Commercial |
$110.76
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
DTAP-HEP B-IPV Vaccine, IM 90723
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3397515
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.47 |
| Max. Negotiated Rate |
$210.44 |
| Rate for Payer: Aetna Commercial |
$210.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$210.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.91
|
| Rate for Payer: Health EOS Commercial |
$201.58
|
| Rate for Payer: HFN Commercial |
$210.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$186.67
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$210.44
|
| Rate for Payer: Quartz Beloit One Network |
$97.47
|
| Rate for Payer: Quartz Commercial |
$126.27
|
| Rate for Payer: The Alliance Commercial |
$110.76
|
| Rate for Payer: United Healthcare Medicaid |
$107.76
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
DTAP-HEP B-IPV Vaccine, IM 90723 VFC Charge
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
5466787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$186.67 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.00
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$186.67
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: United Healthcare Medicaid |
$107.76
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$10.61 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$6.07 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
DTAP-HIB-IP Vaccine, IM 90698
|
Professional
|
Both
|
$285.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3376930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.86 |
| Max. Negotiated Rate |
$281.58 |
| Rate for Payer: Aetna Commercial |
$281.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$281.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$124.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.84
|
| Rate for Payer: Health EOS Commercial |
$269.72
|
| Rate for Payer: HFN Commercial |
$281.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$195.08
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$281.58
|
| Rate for Payer: Quartz Beloit One Network |
$130.42
|
| Rate for Payer: Quartz Commercial |
$168.95
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: United Healthcare Medicaid |
$124.86
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
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 |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
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 |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696
|
Professional
|
Both
|
$166.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3455576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.15 |
| Max. Negotiated Rate |
$164.01 |
| Rate for Payer: Aetna Commercial |
$164.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.47
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$164.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.58
|
| Rate for Payer: Health EOS Commercial |
$157.10
|
| Rate for Payer: HFN Commercial |
$164.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.15
|
| Rate for Payer: Multiplan Commercial |
$138.11
|
| Rate for Payer: Preferred Network Access Commercial |
$164.01
|
| Rate for Payer: Quartz Beloit One Network |
$75.96
|
| Rate for Payer: Quartz Commercial |
$98.40
|
| Rate for Payer: The Alliance Commercial |
$86.32
|
| Rate for Payer: United Healthcare Medicaid |
$67.15
|
| Rate for Payer: WEA Trust Commercial |
$94.95
|
| Rate for Payer: WPS Commercial |
$127.87
|
|
|
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 |
$48.34 |
| Max. Negotiated Rate |
$158.83 |
| Rate for Payer: Aetna Commercial |
$155.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.47
|
| Rate for Payer: Aetna Managed Medicare |
$48.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$112.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.50
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$158.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.61
|
| Rate for Payer: Health EOS Commercial |
$153.65
|
| Rate for Payer: HFN Commercial |
$158.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.48
|
| Rate for Payer: Multiplan Commercial |
$138.11
|
| Rate for Payer: NAPHCARE Commercial |
$103.58
|
| Rate for Payer: Preferred Network Access Commercial |
$158.83
|
| Rate for Payer: Quartz Beloit One Network |
$84.59
|
| Rate for Payer: Quartz Commercial |
$112.22
|
| Rate for Payer: Quartz Medicare Advantage |
$103.58
|
| Rate for Payer: The Alliance Commercial |
$86.32
|
| Rate for Payer: WEA Trust Commercial |
$94.95
|
| Rate for Payer: WPS Commercial |
$127.87
|
|
|
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 |
$84.59 |
| Max. Negotiated Rate |
$158.83 |
| Rate for Payer: Aetna Commercial |
$155.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.50
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$158.83
|
| Rate for Payer: Health EOS Commercial |
$153.65
|
| Rate for Payer: HFN Commercial |
$158.83
|
| Rate for Payer: Multiplan Commercial |
$138.11
|
| Rate for Payer: Preferred Network Access Commercial |
$158.83
|
| Rate for Payer: Quartz Beloit One Network |
$84.59
|
| Rate for Payer: Quartz Commercial |
$103.58
|
| Rate for Payer: WEA Trust Commercial |
$94.95
|
| Rate for Payer: WPS Commercial |
$127.87
|
|
|
DTAP-IPV Vacc 4-6 YR IM 90696 VFC Charge
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
5084633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$112.15 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.00
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.15
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: United Healthcare Medicaid |
$67.15
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$6.07 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$10.61 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
DTAP Vaccine, <7 Yrs, IM 90700
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3455573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$65.52
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
DTAP Vaccine, <7 Yrs, IM 90700
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3455573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.61 |
| Max. Negotiated Rate |
$103.74 |
| Rate for Payer: Aetna Commercial |
$103.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$103.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.52
|
| Rate for Payer: Health EOS Commercial |
$99.37
|
| Rate for Payer: HFN Commercial |
$103.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.89
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$103.74
|
| Rate for Payer: Quartz Beloit One Network |
$48.05
|
| Rate for Payer: Quartz Commercial |
$62.24
|
| Rate for Payer: The Alliance Commercial |
$54.60
|
| Rate for Payer: United Healthcare Medicaid |
$31.61
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
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 |
$30.58 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$30.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.11
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$65.52
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$70.98
|
| Rate for Payer: Quartz Medicare Advantage |
$65.52
|
| Rate for Payer: The Alliance Commercial |
$54.60
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
DTIC-Dome 100 mg Charge
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2958922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$25.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.07
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.86
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$54.29
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$58.81
|
| Rate for Payer: Quartz Medicare Advantage |
$54.29
|
| Rate for Payer: The Alliance Commercial |
$17.14
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$9.59
|
|
