|
Non-State Supplied - DTaP-IPV Charge
|
Professional
|
Both
|
$147.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.15 |
| Max. Negotiated Rate |
$145.24 |
| Rate for Payer: Aetna Commercial |
$145.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$145.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.73
|
| Rate for Payer: Health EOS Commercial |
$139.12
|
| Rate for Payer: HFN Commercial |
$145.24
|
| 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 |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$145.24
|
| Rate for Payer: Quartz Beloit One Network |
$67.27
|
| Rate for Payer: Quartz Commercial |
$87.14
|
| Rate for Payer: The Alliance Commercial |
$76.44
|
| Rate for Payer: United Healthcare Medicaid |
$67.15
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
Non-State Supplied - Hep A Pediatric Charge
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.33 |
| 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: Cigna Commercial |
$83.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.63
|
| 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 |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Non-State Supplied - Hep A Pediatric Charge
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Non-State Supplied - Hep A Pediatric Charge
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.81 |
| Max. Negotiated Rate |
$85.96 |
| Rate for Payer: Aetna Commercial |
$85.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$85.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.29
|
| Rate for Payer: Health EOS Commercial |
$82.34
|
| Rate for Payer: HFN Commercial |
$85.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.68
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$85.96
|
| Rate for Payer: Quartz Beloit One Network |
$39.81
|
| Rate for Payer: Quartz Commercial |
$51.57
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: United Healthcare Medicaid |
$41.59
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Non-State Supplied - Hep B Ped/Adol Charge
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.96 |
| Max. Negotiated Rate |
$86.37 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$34.55
|
| Rate for Payer: Anthem Medicare Advantage |
$34.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34.55
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$47.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.00
|
| Rate for Payer: Health EOS Commercial |
$45.43
|
| Rate for Payer: HFN Commercial |
$47.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$34.55
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$51.82
|
| Rate for Payer: Preferred Network Access Commercial |
$47.42
|
| Rate for Payer: Quartz Beloit One Network |
$21.96
|
| Rate for Payer: Quartz Commercial |
$28.45
|
| Rate for Payer: Quartz Medicare Advantage |
$34.55
|
| Rate for Payer: The Alliance Commercial |
$86.37
|
| Rate for Payer: United Healthcare Medicaid |
$30.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.55
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
Non-State Supplied - Hep B Ped/Adol Charge
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$138.20 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.34
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.44
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$32.45
|
| Rate for Payer: Quartz Medicare Advantage |
$29.95
|
| Rate for Payer: The Alliance Commercial |
$138.20
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
Non-State Supplied - Hep B Ped/Adol Charge
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$29.95
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Non-State Supplied - HIB Charge
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.17 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$151.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.89
|
| Rate for Payer: Aetna Managed Medicare |
$47.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$109.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$80.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.29
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$155.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.28
|
| Rate for Payer: Health EOS Commercial |
$149.95
|
| Rate for Payer: HFN Commercial |
$155.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$126.36
|
| Rate for Payer: Multiplan Commercial |
$134.78
|
| Rate for Payer: NAPHCARE Commercial |
$101.09
|
| Rate for Payer: Preferred Network Access Commercial |
$155.00
|
| Rate for Payer: Quartz Beloit One Network |
$82.56
|
| Rate for Payer: Quartz Commercial |
$109.51
|
| Rate for Payer: Quartz Medicare Advantage |
$101.09
|
| Rate for Payer: The Alliance Commercial |
$84.24
|
| Rate for Payer: WEA Trust Commercial |
$92.66
|
| Rate for Payer: WPS Commercial |
$124.79
|
|
|
Non-State Supplied - HIB Charge
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.95 |
| Max. Negotiated Rate |
$160.06 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.89
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$160.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.09
|
| Rate for Payer: Health EOS Commercial |
$153.32
|
| Rate for Payer: HFN Commercial |
$160.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$134.78
|
| Rate for Payer: Preferred Network Access Commercial |
$160.06
|
| Rate for Payer: Quartz Beloit One Network |
$74.13
|
| Rate for Payer: Quartz Commercial |
$96.03
|
| Rate for Payer: The Alliance Commercial |
$84.24
|
| Rate for Payer: United Healthcare Medicaid |
$13.95
|
| Rate for Payer: WEA Trust Commercial |
$92.66
|
| Rate for Payer: WPS Commercial |
$124.79
|
|
|
Non-State Supplied - HIB Charge
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$151.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.29
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$155.00
|
| Rate for Payer: Health EOS Commercial |
$149.95
|
| Rate for Payer: HFN Commercial |
$155.00
|
| Rate for Payer: Multiplan Commercial |
$134.78
|
| Rate for Payer: Preferred Network Access Commercial |
$155.00
|
| Rate for Payer: Quartz Beloit One Network |
$82.56
|
| Rate for Payer: Quartz Commercial |
$101.09
|
| Rate for Payer: WEA Trust Commercial |
$92.66
|
| Rate for Payer: WPS Commercial |
$124.79
|
|
|
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 |
$62.68 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$76.75
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
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 |
$32.73 |
| Max. Negotiated Rate |
$121.52 |
| Rate for Payer: Aetna Commercial |
$121.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$121.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.75
|
| Rate for Payer: Health EOS Commercial |
$116.41
|
| Rate for Payer: HFN Commercial |
$121.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.95
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$121.52
|
| Rate for Payer: Quartz Beloit One Network |
$56.28
|
| Rate for Payer: Quartz Commercial |
$72.91
|
| Rate for Payer: The Alliance Commercial |
$63.96
|
| Rate for Payer: United Healthcare Medicaid |
$32.73
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
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 |
$35.82 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Aetna Managed Medicare |
$35.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.59
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.94
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: NAPHCARE Commercial |
$76.75
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$83.15
|
| Rate for Payer: Quartz Medicare Advantage |
$76.75
|
| Rate for Payer: The Alliance Commercial |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
Non-State Supplied - HPV Charge
|
Facility
|
IP
|
$518.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
2474806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$263.97 |
| Max. Negotiated Rate |
$495.62 |
| Rate for Payer: Aetna Commercial |
$484.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$463.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$285.52
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$495.62
|
| Rate for Payer: Health EOS Commercial |
$479.46
|
| Rate for Payer: HFN Commercial |
$495.62
|
| Rate for Payer: Multiplan Commercial |
$430.98
|
| Rate for Payer: Preferred Network Access Commercial |
$495.62
|
| Rate for Payer: Quartz Beloit One Network |
$263.97
|
| Rate for Payer: Quartz Commercial |
$323.23
|
| Rate for Payer: WEA Trust Commercial |
$296.30
|
| Rate for Payer: WPS Commercial |
$399.02
|
|
|
Non-State Supplied - HPV Charge
|
Professional
|
Both
|
$518.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
2474806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$237.04 |
| Max. Negotiated Rate |
$511.78 |
| Rate for Payer: Aetna Commercial |
$511.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$463.30
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$511.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$269.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$323.23
|
| Rate for Payer: Health EOS Commercial |
$490.24
|
| Rate for Payer: HFN Commercial |
$511.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$277.04
|
| Rate for Payer: Multiplan Commercial |
$430.98
|
| Rate for Payer: Preferred Network Access Commercial |
$511.78
|
| Rate for Payer: Quartz Beloit One Network |
$237.04
|
| Rate for Payer: Quartz Commercial |
$307.07
|
| Rate for Payer: The Alliance Commercial |
$269.36
|
| Rate for Payer: WEA Trust Commercial |
$296.30
|
| Rate for Payer: WPS Commercial |
$399.02
|
|
|
Non-State Supplied - HPV Charge
|
Facility
|
OP
|
$518.00
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
2474806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.84 |
| Max. Negotiated Rate |
$495.62 |
| Rate for Payer: Aetna Commercial |
$484.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$463.30
|
| Rate for Payer: Aetna Managed Medicare |
$150.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$258.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$285.52
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$495.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$301.48
|
| Rate for Payer: Health EOS Commercial |
$479.46
|
| Rate for Payer: HFN Commercial |
$495.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.04
|
| Rate for Payer: Multiplan Commercial |
$430.98
|
| Rate for Payer: NAPHCARE Commercial |
$323.23
|
| Rate for Payer: Preferred Network Access Commercial |
$495.62
|
| Rate for Payer: Quartz Beloit One Network |
$263.97
|
| Rate for Payer: Quartz Commercial |
$350.17
|
| Rate for Payer: Quartz Medicare Advantage |
$323.23
|
| Rate for Payer: The Alliance Commercial |
$269.36
|
| Rate for Payer: WEA Trust Commercial |
$296.30
|
| Rate for Payer: WPS Commercial |
$399.02
|
|
|
Non-State Supplied - Menactra Charge
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
4546744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.42 |
| Max. Negotiated Rate |
$393.22 |
| Rate for Payer: Aetna Commercial |
$393.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$393.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$173.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$248.35
|
| Rate for Payer: Health EOS Commercial |
$376.67
|
| Rate for Payer: HFN Commercial |
$393.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$233.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$233.06
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: Preferred Network Access Commercial |
$393.22
|
| Rate for Payer: Quartz Beloit One Network |
$182.12
|
| Rate for Payer: Quartz Commercial |
$235.93
|
| Rate for Payer: The Alliance Commercial |
$206.96
|
| Rate for Payer: United Healthcare Medicaid |
$173.42
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
Non-State Supplied - Menactra Charge
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
4546744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.90 |
| Max. Negotiated Rate |
$380.81 |
| Rate for Payer: Aetna Commercial |
$372.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Aetna Managed Medicare |
$115.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$269.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$206.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$198.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.38
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$380.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.64
|
| Rate for Payer: Health EOS Commercial |
$368.39
|
| Rate for Payer: HFN Commercial |
$380.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$310.44
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: NAPHCARE Commercial |
$248.35
|
| Rate for Payer: Preferred Network Access Commercial |
$380.81
|
| Rate for Payer: Quartz Beloit One Network |
$202.82
|
| Rate for Payer: Quartz Commercial |
$269.05
|
| Rate for Payer: Quartz Medicare Advantage |
$248.35
|
| Rate for Payer: The Alliance Commercial |
$206.96
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
Non-State Supplied - Menactra Charge
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
4546744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.82 |
| Max. Negotiated Rate |
$380.81 |
| Rate for Payer: Aetna Commercial |
$372.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.38
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$380.81
|
| Rate for Payer: Health EOS Commercial |
$368.39
|
| Rate for Payer: HFN Commercial |
$380.81
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: Preferred Network Access Commercial |
$380.81
|
| Rate for Payer: Quartz Beloit One Network |
$202.82
|
| Rate for Payer: Quartz Commercial |
$248.35
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
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 |
$188.04 |
| Max. Negotiated Rate |
$353.06 |
| Rate for Payer: Aetna Commercial |
$345.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.39
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$353.06
|
| Rate for Payer: Health EOS Commercial |
$341.55
|
| Rate for Payer: HFN Commercial |
$353.06
|
| Rate for Payer: Multiplan Commercial |
$307.01
|
| Rate for Payer: Preferred Network Access Commercial |
$353.06
|
| Rate for Payer: Quartz Beloit One Network |
$188.04
|
| Rate for Payer: Quartz Commercial |
$230.26
|
| Rate for Payer: WEA Trust Commercial |
$211.07
|
| Rate for Payer: WPS Commercial |
$284.24
|
|
|
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 |
$107.45 |
| Max. Negotiated Rate |
$353.06 |
| Rate for Payer: Aetna Commercial |
$345.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.03
|
| Rate for Payer: Aetna Managed Medicare |
$107.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$249.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$191.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$184.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.39
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$353.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$214.76
|
| Rate for Payer: Health EOS Commercial |
$341.55
|
| Rate for Payer: HFN Commercial |
$353.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$287.82
|
| Rate for Payer: Multiplan Commercial |
$307.01
|
| Rate for Payer: NAPHCARE Commercial |
$230.26
|
| Rate for Payer: Preferred Network Access Commercial |
$353.06
|
| Rate for Payer: Quartz Beloit One Network |
$188.04
|
| Rate for Payer: Quartz Commercial |
$249.44
|
| Rate for Payer: Quartz Medicare Advantage |
$230.26
|
| Rate for Payer: The Alliance Commercial |
$191.88
|
| Rate for Payer: WEA Trust Commercial |
$211.07
|
| Rate for Payer: WPS Commercial |
$284.24
|
|
|
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 |
$168.85 |
| Max. Negotiated Rate |
$364.57 |
| Rate for Payer: Aetna Commercial |
$364.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.03
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$364.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$191.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.26
|
| Rate for Payer: Health EOS Commercial |
$349.22
|
| Rate for Payer: HFN Commercial |
$364.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$224.19
|
| Rate for Payer: Multiplan Commercial |
$307.01
|
| Rate for Payer: Preferred Network Access Commercial |
$364.57
|
| Rate for Payer: Quartz Beloit One Network |
$168.85
|
| Rate for Payer: Quartz Commercial |
$218.74
|
| Rate for Payer: The Alliance Commercial |
$191.88
|
| Rate for Payer: WEA Trust Commercial |
$211.07
|
| Rate for Payer: WPS Commercial |
$284.24
|
|
|
Non-State Supplied - Menveo Charge
|
Facility
|
IP
|
$361.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5094630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.97 |
| Max. Negotiated Rate |
$345.40 |
| Rate for Payer: Aetna Commercial |
$337.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.98
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cigna Commercial |
$345.40
|
| Rate for Payer: Health EOS Commercial |
$334.14
|
| Rate for Payer: HFN Commercial |
$345.40
|
| Rate for Payer: Multiplan Commercial |
$300.35
|
| Rate for Payer: Preferred Network Access Commercial |
$345.40
|
| Rate for Payer: Quartz Beloit One Network |
$183.97
|
| Rate for Payer: Quartz Commercial |
$225.26
|
| Rate for Payer: WEA Trust Commercial |
$206.49
|
| Rate for Payer: WPS Commercial |
$278.08
|
|
|
Non-State Supplied - Menveo Charge
|
Professional
|
Both
|
$361.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5094630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.19 |
| Max. Negotiated Rate |
$356.67 |
| Rate for Payer: Aetna Commercial |
$356.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.88
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cigna Commercial |
$356.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$173.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$225.26
|
| Rate for Payer: Health EOS Commercial |
$341.65
|
| Rate for Payer: HFN Commercial |
$356.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$233.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$233.06
|
| Rate for Payer: Multiplan Commercial |
$300.35
|
| Rate for Payer: Preferred Network Access Commercial |
$356.67
|
| Rate for Payer: Quartz Beloit One Network |
$165.19
|
| Rate for Payer: Quartz Commercial |
$214.00
|
| Rate for Payer: The Alliance Commercial |
$187.72
|
| Rate for Payer: United Healthcare Medicaid |
$173.42
|
| Rate for Payer: WEA Trust Commercial |
$206.49
|
| Rate for Payer: WPS Commercial |
$278.08
|
|
|
Non-State Supplied - Menveo Charge
|
Facility
|
OP
|
$361.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5094630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.12 |
| Max. Negotiated Rate |
$345.40 |
| Rate for Payer: Aetna Commercial |
$337.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.88
|
| Rate for Payer: Aetna Managed Medicare |
$105.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$244.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$187.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$180.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.98
|
| Rate for Payer: Cash Price |
$108.30
|
| Rate for Payer: Cigna Commercial |
$345.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$210.10
|
| Rate for Payer: Health EOS Commercial |
$334.14
|
| Rate for Payer: HFN Commercial |
$345.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.58
|
| Rate for Payer: Multiplan Commercial |
$300.35
|
| Rate for Payer: NAPHCARE Commercial |
$225.26
|
| Rate for Payer: Preferred Network Access Commercial |
$345.40
|
| Rate for Payer: Quartz Beloit One Network |
$183.97
|
| Rate for Payer: Quartz Commercial |
$244.04
|
| Rate for Payer: Quartz Medicare Advantage |
$225.26
|
| Rate for Payer: The Alliance Commercial |
$187.72
|
| Rate for Payer: WEA Trust Commercial |
$206.49
|
| Rate for Payer: WPS Commercial |
$278.08
|
|
