|
Non-State Supplied - HIB Charge
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.04 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$153.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.20
|
| Rate for Payer: Health EOS Commercial |
$147.42
|
| Rate for Payer: HFN Commercial |
$153.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.04
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$153.90
|
| Rate for Payer: Quartz Beloit One Network |
$71.28
|
| Rate for Payer: Quartz Commercial |
$92.34
|
| Rate for Payer: The Alliance Commercial |
$81.00
|
| Rate for Payer: United Healthcare Medicaid |
$45.80
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Non-State Supplied - HIB Charge
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.36 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna Commercial |
$145.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Aetna Managed Medicare |
$45.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.86
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$149.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.66
|
| Rate for Payer: Health EOS Commercial |
$144.18
|
| Rate for Payer: HFN Commercial |
$149.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.50
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: NAPHCARE Commercial |
$97.20
|
| Rate for Payer: Preferred Network Access Commercial |
$149.04
|
| Rate for Payer: Quartz Beloit One Network |
$79.38
|
| Rate for Payer: Quartz Commercial |
$105.30
|
| Rate for Payer: Quartz Medicare Advantage |
$97.20
|
| Rate for Payer: The Alliance Commercial |
$648.00
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Non-State Supplied - HIB Charge
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.38 |
| Max. Negotiated Rate |
$149.04 |
| Rate for Payer: Aetna Commercial |
$145.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.86
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$149.04
|
| Rate for Payer: Health EOS Commercial |
$144.18
|
| Rate for Payer: HFN Commercial |
$149.04
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: NAPHCARE Commercial |
$97.20
|
| Rate for Payer: Preferred Network Access Commercial |
$149.04
|
| Rate for Payer: Quartz Beloit One Network |
$79.38
|
| Rate for Payer: Quartz Commercial |
$97.20
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Non-State Supplied - HIB Vaccine, PRP-OPM Charge
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
CPT 90647
|
| Hospital Charge Code |
5587598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Non-State Supplied - HIB Vaccine, PRP-OPM Charge
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 90647
|
| Hospital Charge Code |
5587598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$73.80
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Non-State Supplied - HIB Vaccine, PRP-OPM Charge
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
CPT 90647
|
| Hospital Charge Code |
5587598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.96 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Aetna Commercial |
$116.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$116.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.80
|
| Rate for Payer: Health EOS Commercial |
$111.93
|
| Rate for Payer: HFN Commercial |
$116.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.14
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$116.85
|
| Rate for Payer: Quartz Beloit One Network |
$54.12
|
| Rate for Payer: Quartz Commercial |
$70.11
|
| Rate for Payer: The Alliance Commercial |
$61.50
|
| Rate for Payer: United Healthcare Medicaid |
$41.96
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Non-State Supplied - HPV Charge
|
Facility
|
OP
|
$518.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
2474806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.04 |
| Max. Negotiated Rate |
$2,072.00 |
| Rate for Payer: Aetna Commercial |
$466.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.48
|
| Rate for Payer: Aetna Managed Medicare |
$145.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$248.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.54
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$476.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.87
|
| Rate for Payer: Health EOS Commercial |
$461.02
|
| Rate for Payer: HFN Commercial |
$476.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$388.50
|
| Rate for Payer: Multiplan Commercial |
$414.40
|
| Rate for Payer: NAPHCARE Commercial |
$310.80
|
| Rate for Payer: Preferred Network Access Commercial |
$476.56
|
| Rate for Payer: Quartz Beloit One Network |
$253.82
|
| Rate for Payer: Quartz Commercial |
$336.70
|
| Rate for Payer: Quartz Medicare Advantage |
$310.80
|
| Rate for Payer: The Alliance Commercial |
$2,072.00
|
| Rate for Payer: WEA Trust Commercial |
$284.90
|
| Rate for Payer: WPS Commercial |
$383.68
|
|
|
Non-State Supplied - HPV Charge
|
Facility
|
IP
|
$518.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
2474806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$253.82 |
| Max. Negotiated Rate |
$476.56 |
| Rate for Payer: Aetna Commercial |
$466.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.54
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$476.56
|
| Rate for Payer: Health EOS Commercial |
$461.02
|
| Rate for Payer: HFN Commercial |
$476.56
|
| Rate for Payer: Multiplan Commercial |
$414.40
|
| Rate for Payer: NAPHCARE Commercial |
$310.80
|
| Rate for Payer: Preferred Network Access Commercial |
$476.56
|
| Rate for Payer: Quartz Beloit One Network |
$253.82
|
| Rate for Payer: Quartz Commercial |
$310.80
|
| Rate for Payer: WEA Trust Commercial |
$284.90
|
| Rate for Payer: WPS Commercial |
$383.68
|
|
|
Non-State Supplied - HPV Charge
|
Professional
|
Both
|
$518.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
2474806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$492.10 |
| Rate for Payer: Aetna Commercial |
$492.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.48
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$492.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$310.80
|
| Rate for Payer: Health EOS Commercial |
$471.38
|
| Rate for Payer: HFN Commercial |
$492.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$266.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$266.38
|
| Rate for Payer: Multiplan Commercial |
$414.40
|
| Rate for Payer: Preferred Network Access Commercial |
$492.10
|
| Rate for Payer: Quartz Beloit One Network |
$227.92
|
| Rate for Payer: Quartz Commercial |
$295.26
|
| Rate for Payer: The Alliance Commercial |
$259.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$284.90
|
| Rate for Payer: WPS Commercial |
$383.68
|
|
|
Non-State Supplied - Menactra Charge
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
4546744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$195.02 |
| Max. Negotiated Rate |
$366.16 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$238.80
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$238.80
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Non-State Supplied - Menactra Charge
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
4546744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$163.49 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna Commercial |
$378.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$378.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.80
|
| Rate for Payer: Health EOS Commercial |
$362.18
|
| Rate for Payer: HFN Commercial |
$378.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$224.10
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: Preferred Network Access Commercial |
$378.10
|
| Rate for Payer: Quartz Beloit One Network |
$175.12
|
| Rate for Payer: Quartz Commercial |
$226.86
|
| Rate for Payer: The Alliance Commercial |
$199.00
|
| Rate for Payer: United Healthcare Medicaid |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Non-State Supplied - Menactra Charge
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
4546744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.44 |
| Max. Negotiated Rate |
$1,592.00 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Aetna Managed Medicare |
$111.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$199.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$191.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.72
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.50
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$238.80
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$258.70
|
| Rate for Payer: Quartz Medicare Advantage |
$238.80
|
| Rate for Payer: The Alliance Commercial |
$1,592.00
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Non-State Supplied - Meningococcal (Menomune) Charge
|
Professional
|
Both
|
$369.00
|
|
|
Service Code
|
CPT 90733
|
| Hospital Charge Code |
3912012
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.49 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna Commercial |
$350.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$317.34
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$350.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$221.40
|
| Rate for Payer: Health EOS Commercial |
$335.79
|
| Rate for Payer: HFN Commercial |
$350.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$215.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$215.57
|
| Rate for Payer: Multiplan Commercial |
$295.20
|
| Rate for Payer: Preferred Network Access Commercial |
$350.55
|
| Rate for Payer: Quartz Beloit One Network |
$162.36
|
| Rate for Payer: Quartz Commercial |
$210.33
|
| Rate for Payer: The Alliance Commercial |
$184.50
|
| Rate for Payer: United Healthcare Medicaid |
$121.49
|
| Rate for Payer: WEA Trust Commercial |
$202.95
|
| Rate for Payer: WPS Commercial |
$273.32
|
|
|
Non-State Supplied - Meningococcal (Menomune) Charge
|
Facility
|
OP
|
$369.00
|
|
|
Service Code
|
CPT 90733
|
| Hospital Charge Code |
3912012
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.32 |
| Max. Negotiated Rate |
$1,476.00 |
| Rate for Payer: Aetna Commercial |
$332.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$317.34
|
| Rate for Payer: Aetna Managed Medicare |
$103.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.57
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$339.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.49
|
| Rate for Payer: Health EOS Commercial |
$328.41
|
| Rate for Payer: HFN Commercial |
$339.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.75
|
| Rate for Payer: Multiplan Commercial |
$295.20
|
| Rate for Payer: NAPHCARE Commercial |
$221.40
|
| Rate for Payer: Preferred Network Access Commercial |
$339.48
|
| Rate for Payer: Quartz Beloit One Network |
$180.81
|
| Rate for Payer: Quartz Commercial |
$239.85
|
| Rate for Payer: Quartz Medicare Advantage |
$221.40
|
| Rate for Payer: The Alliance Commercial |
$1,476.00
|
| Rate for Payer: WEA Trust Commercial |
$202.95
|
| Rate for Payer: WPS Commercial |
$273.32
|
|
|
Non-State Supplied - Meningococcal (Menomune) Charge
|
Facility
|
IP
|
$369.00
|
|
|
Service Code
|
CPT 90733
|
| Hospital Charge Code |
3912012
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.81 |
| Max. Negotiated Rate |
$339.48 |
| Rate for Payer: Aetna Commercial |
$332.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$317.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.57
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$339.48
|
| Rate for Payer: Health EOS Commercial |
$328.41
|
| Rate for Payer: HFN Commercial |
$339.48
|
| Rate for Payer: Multiplan Commercial |
$295.20
|
| Rate for Payer: NAPHCARE Commercial |
$221.40
|
| Rate for Payer: Preferred Network Access Commercial |
$339.48
|
| Rate for Payer: Quartz Beloit One Network |
$180.81
|
| Rate for Payer: Quartz Commercial |
$221.40
|
| Rate for Payer: WEA Trust Commercial |
$202.95
|
| Rate for Payer: WPS Commercial |
$273.32
|
|
|
Non-State Supplied - Menveo Charge
|
Professional
|
Both
|
$361.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5094630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.84 |
| Max. Negotiated Rate |
$342.95 |
| Rate for Payer: Aetna Commercial |
$342.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$310.46
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cigna Commercial |
$342.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$216.60
|
| Rate for Payer: Health EOS Commercial |
$328.51
|
| Rate for Payer: HFN Commercial |
$342.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$224.10
|
| Rate for Payer: Multiplan Commercial |
$288.80
|
| Rate for Payer: Preferred Network Access Commercial |
$342.95
|
| Rate for Payer: Quartz Beloit One Network |
$158.84
|
| Rate for Payer: Quartz Commercial |
$205.77
|
| Rate for Payer: The Alliance Commercial |
$180.50
|
| Rate for Payer: United Healthcare Medicaid |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$198.55
|
| Rate for Payer: WPS Commercial |
$267.39
|
|
|
Non-State Supplied - Menveo Charge
|
Facility
|
IP
|
$361.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5094630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$176.89 |
| Max. Negotiated Rate |
$332.12 |
| Rate for Payer: Aetna Commercial |
$324.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$310.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.33
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cigna Commercial |
$332.12
|
| Rate for Payer: Health EOS Commercial |
$321.29
|
| Rate for Payer: HFN Commercial |
$332.12
|
| Rate for Payer: Multiplan Commercial |
$288.80
|
| Rate for Payer: NAPHCARE Commercial |
$216.60
|
| Rate for Payer: Preferred Network Access Commercial |
$332.12
|
| Rate for Payer: Quartz Beloit One Network |
$176.89
|
| Rate for Payer: Quartz Commercial |
$216.60
|
| Rate for Payer: WEA Trust Commercial |
$198.55
|
| Rate for Payer: WPS Commercial |
$267.39
|
|
|
Non-State Supplied - Menveo Charge
|
Facility
|
OP
|
$361.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5094630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.08 |
| Max. Negotiated Rate |
$1,444.00 |
| Rate for Payer: Aetna Commercial |
$324.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$310.46
|
| Rate for Payer: Aetna Managed Medicare |
$101.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$234.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$180.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$173.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.33
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cigna Commercial |
$332.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$202.02
|
| Rate for Payer: Health EOS Commercial |
$321.29
|
| Rate for Payer: HFN Commercial |
$332.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$270.75
|
| Rate for Payer: Multiplan Commercial |
$288.80
|
| Rate for Payer: NAPHCARE Commercial |
$216.60
|
| Rate for Payer: Preferred Network Access Commercial |
$332.12
|
| Rate for Payer: Quartz Beloit One Network |
$176.89
|
| Rate for Payer: Quartz Commercial |
$234.65
|
| Rate for Payer: Quartz Medicare Advantage |
$216.60
|
| Rate for Payer: The Alliance Commercial |
$1,444.00
|
| Rate for Payer: WEA Trust Commercial |
$198.55
|
| Rate for Payer: WPS Commercial |
$267.39
|
|
|
Non-State Supplied - MMR Charge
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3013478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$824.00 |
| Rate for Payer: Aetna Commercial |
$185.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.16
|
| Rate for Payer: Aetna Managed Medicare |
$57.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$103.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.18
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$189.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.28
|
| Rate for Payer: Health EOS Commercial |
$183.34
|
| Rate for Payer: HFN Commercial |
$189.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$154.50
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: NAPHCARE Commercial |
$123.60
|
| Rate for Payer: Preferred Network Access Commercial |
$189.52
|
| Rate for Payer: Quartz Beloit One Network |
$100.94
|
| Rate for Payer: Quartz Commercial |
$133.90
|
| Rate for Payer: Quartz Medicare Advantage |
$123.60
|
| Rate for Payer: The Alliance Commercial |
$824.00
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: WPS Commercial |
$152.58
|
|
|
Non-State Supplied - MMR Charge
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3013478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.94 |
| Max. Negotiated Rate |
$189.52 |
| Rate for Payer: Aetna Commercial |
$185.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.18
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$189.52
|
| Rate for Payer: Health EOS Commercial |
$183.34
|
| Rate for Payer: HFN Commercial |
$189.52
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: NAPHCARE Commercial |
$123.60
|
| Rate for Payer: Preferred Network Access Commercial |
$189.52
|
| Rate for Payer: Quartz Beloit One Network |
$100.94
|
| Rate for Payer: Quartz Commercial |
$123.60
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: WPS Commercial |
$152.58
|
|
|
Non-State Supplied - MMR Charge
|
Professional
|
Both
|
$206.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3013478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.64 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Aetna Commercial |
$195.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.16
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$195.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.60
|
| Rate for Payer: Health EOS Commercial |
$187.46
|
| Rate for Payer: HFN Commercial |
$195.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.69
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: Preferred Network Access Commercial |
$195.70
|
| Rate for Payer: Quartz Beloit One Network |
$90.64
|
| Rate for Payer: Quartz Commercial |
$117.42
|
| Rate for Payer: The Alliance Commercial |
$103.00
|
| Rate for Payer: United Healthcare Medicaid |
$104.87
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: WPS Commercial |
$152.58
|
|
|
Non-State Supplied - MMR-Varicella Charge
|
Facility
|
IP
|
$387.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3013475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.63 |
| Max. Negotiated Rate |
$356.04 |
| Rate for Payer: Aetna Commercial |
$348.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$332.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.11
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$356.04
|
| Rate for Payer: Health EOS Commercial |
$344.43
|
| Rate for Payer: HFN Commercial |
$356.04
|
| Rate for Payer: Multiplan Commercial |
$309.60
|
| Rate for Payer: NAPHCARE Commercial |
$232.20
|
| Rate for Payer: Preferred Network Access Commercial |
$356.04
|
| Rate for Payer: Quartz Beloit One Network |
$189.63
|
| Rate for Payer: Quartz Commercial |
$232.20
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: WPS Commercial |
$286.65
|
|
|
Non-State Supplied - MMR-Varicella Charge
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3013475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.65 |
| Max. Negotiated Rate |
$550.60 |
| Rate for Payer: Aetna Commercial |
$348.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$332.82
|
| Rate for Payer: Aetna Managed Medicare |
$137.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$251.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$193.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$185.76
|
| Rate for Payer: Anthem Medicare Advantage |
$137.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.65
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$356.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$137.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$216.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$137.65
|
| Rate for Payer: Health EOS Commercial |
$344.43
|
| Rate for Payer: HFN Commercial |
$356.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$512.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$137.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$137.65
|
| Rate for Payer: Multiplan Commercial |
$309.60
|
| Rate for Payer: NAPHCARE Commercial |
$206.48
|
| Rate for Payer: Preferred Network Access Commercial |
$356.04
|
| Rate for Payer: Quartz Beloit One Network |
$189.63
|
| Rate for Payer: Quartz Commercial |
$251.55
|
| Rate for Payer: Quartz Medicare Advantage |
$137.65
|
| Rate for Payer: The Alliance Commercial |
$550.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.65
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: Wellcare Medicare |
$137.65
|
| Rate for Payer: WPS Commercial |
$286.65
|
|
|
Non-State Supplied - MMR-Varicella Charge
|
Professional
|
Both
|
$387.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3013475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.28 |
| Max. Negotiated Rate |
$408.08 |
| Rate for Payer: Aetna Commercial |
$367.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$332.82
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$367.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.20
|
| Rate for Payer: Health EOS Commercial |
$352.17
|
| Rate for Payer: HFN Commercial |
$367.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$408.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$408.08
|
| Rate for Payer: Multiplan Commercial |
$309.60
|
| Rate for Payer: Preferred Network Access Commercial |
$367.65
|
| Rate for Payer: Quartz Beloit One Network |
$170.28
|
| Rate for Payer: Quartz Commercial |
$220.59
|
| Rate for Payer: The Alliance Commercial |
$193.50
|
| Rate for Payer: United Healthcare Medicaid |
$195.05
|
| Rate for Payer: WEA Trust Commercial |
$212.85
|
| Rate for Payer: WPS Commercial |
$286.65
|
|
|
Non-State Supplied - Pentacel Charge
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
3513533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$1,320.00 |
| Rate for Payer: Aetna Commercial |
$297.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.80
|
| Rate for Payer: Aetna Managed Medicare |
$92.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$214.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$165.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$303.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.67
|
| Rate for Payer: Health EOS Commercial |
$293.70
|
| Rate for Payer: HFN Commercial |
$303.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.50
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: NAPHCARE Commercial |
$198.00
|
| Rate for Payer: Preferred Network Access Commercial |
$303.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.70
|
| Rate for Payer: Quartz Commercial |
$214.50
|
| Rate for Payer: Quartz Medicare Advantage |
$198.00
|
| Rate for Payer: The Alliance Commercial |
$1,320.00
|
| Rate for Payer: WEA Trust Commercial |
$181.50
|
| Rate for Payer: WPS Commercial |
$244.43
|
|
