|
STAPLE SYSTEM 15MM X 15MM 500-15-001
|
Facility
OP
|
$5,824.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.72 |
| Max. Negotiated Rate |
$5,358.08 |
| Rate for Payer: Aetna Commercial |
$5,241.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,008.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,630.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,785.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,912.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,795.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,086.72
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cigna Commercial |
$5,358.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,259.11
|
| Rate for Payer: Health EOS Commercial |
$5,183.36
|
| Rate for Payer: HFN Commercial |
$5,358.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,368.00
|
| Rate for Payer: Multiplan Commercial |
$4,659.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,494.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,358.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,853.76
|
| Rate for Payer: Quartz Commercial |
$3,785.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,494.40
|
| Rate for Payer: WEA Trust Commercial |
$3,203.20
|
| Rate for Payer: WPS Commercial |
$4,313.84
|
|
|
STAPLE SYSTEM 15MM X 15MM 500-15-001
|
Facility
IP
|
$5,824.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,853.76 |
| Max. Negotiated Rate |
$5,358.08 |
| Rate for Payer: Aetna Commercial |
$5,241.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,086.72
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cigna Commercial |
$5,358.08
|
| Rate for Payer: Health EOS Commercial |
$5,183.36
|
| Rate for Payer: HFN Commercial |
$5,358.08
|
| Rate for Payer: Multiplan Commercial |
$4,659.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,494.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,358.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,853.76
|
| Rate for Payer: Quartz Commercial |
$3,494.40
|
| Rate for Payer: WEA Trust Commercial |
$3,203.20
|
| Rate for Payer: WPS Commercial |
$4,313.84
|
|
|
State Supplied - Bexsero Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Bexsero Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Bexsero Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$286.95 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$286.95
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$226.32
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTap Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTap Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$43.16 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.16
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTap Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Dtap-Hep B-IPV Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3912011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Dtap-Hep B-IPV Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3912011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$179.49 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$179.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.49
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Dtap-Hep B-IPV Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3912011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTaP-IPV Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTaP-IPV Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - DTaP-IPV Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$107.84 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.84
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Hep A Pediatric Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Hep A Pediatric Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$57.38 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.38
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Hep A Pediatric Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Hep B Ped/Adol Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$81.85 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$29.90
|
| Rate for Payer: Anthem Medicare Advantage |
$29.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.90
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.77
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$41.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.90
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: Quartz Medicare Advantage |
$29.90
|
| Rate for Payer: The Alliance Commercial |
$74.74
|
| Rate for Payer: United Healthcare Medicaid |
$81.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.90
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$76.92
|
|
|
State Supplied - Hep B Ped/Adol Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Hep B Ped/Adol Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$76.92 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.71
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$7.70
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$76.92
|
|
|
State Supplied - Hep B (Recombivax) Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
3947958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$76.92 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.71
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$7.70
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$76.92
|
|
|
State Supplied - Hep B (Recombivax) Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
3947958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$81.85 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$29.90
|
| Rate for Payer: Anthem Medicare Advantage |
$29.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.90
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.77
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$41.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.90
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: Quartz Medicare Advantage |
$29.90
|
| Rate for Payer: The Alliance Commercial |
$74.74
|
| Rate for Payer: United Healthcare Medicaid |
$81.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.90
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$76.92
|
|
|
State Supplied - Hep B (Recombivax) Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
3947958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - HIB Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - HIB Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
