|
STAPLE SYSTEM 10MM X 10MM SNIPER 500-10-101
|
Facility
|
IP
|
$7,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,780.72 |
| Max. Negotiated Rate |
$7,098.50 |
| Rate for Payer: Aetna Commercial |
$6,944.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,635.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,089.35
|
| Rate for Payer: Cash Price |
$2,225.70
|
| Rate for Payer: Cigna Commercial |
$7,098.50
|
| Rate for Payer: Health EOS Commercial |
$6,867.03
|
| Rate for Payer: HFN Commercial |
$7,098.50
|
| Rate for Payer: Multiplan Commercial |
$6,172.61
|
| Rate for Payer: Preferred Network Access Commercial |
$7,098.50
|
| Rate for Payer: Quartz Beloit One Network |
$3,780.72
|
| Rate for Payer: Quartz Commercial |
$4,629.46
|
| Rate for Payer: WEA Trust Commercial |
$4,243.67
|
| Rate for Payer: WPS Commercial |
$5,714.86
|
|
|
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 |
$1,695.95 |
| Max. Negotiated Rate |
$5,572.40 |
| Rate for Payer: Aetna Commercial |
$5,451.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,208.99
|
| Rate for Payer: Aetna Managed Medicare |
$1,695.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,937.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,028.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,907.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,210.19
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cigna Commercial |
$5,572.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,389.57
|
| Rate for Payer: Health EOS Commercial |
$5,390.69
|
| Rate for Payer: HFN Commercial |
$5,572.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,542.72
|
| Rate for Payer: Multiplan Commercial |
$4,845.57
|
| Rate for Payer: NAPHCARE Commercial |
$3,634.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,572.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,967.91
|
| Rate for Payer: Quartz Commercial |
$3,937.02
|
| Rate for Payer: Quartz Medicare Advantage |
$3,634.18
|
| Rate for Payer: The Alliance Commercial |
$3,028.48
|
| Rate for Payer: WEA Trust Commercial |
$3,331.33
|
| Rate for Payer: WPS Commercial |
$4,486.23
|
|
|
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 |
$2,967.91 |
| Max. Negotiated Rate |
$5,572.40 |
| Rate for Payer: Aetna Commercial |
$5,451.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,208.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,210.19
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cigna Commercial |
$5,572.40
|
| Rate for Payer: Health EOS Commercial |
$5,390.69
|
| Rate for Payer: HFN Commercial |
$5,572.40
|
| Rate for Payer: Multiplan Commercial |
$4,845.57
|
| Rate for Payer: Preferred Network Access Commercial |
$5,572.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,967.91
|
| Rate for Payer: Quartz Commercial |
$3,634.18
|
| Rate for Payer: WEA Trust Commercial |
$3,331.33
|
| Rate for Payer: WPS Commercial |
$4,486.23
|
|
|
State Supplied - Bexsero Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Bexsero Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$298.43 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$246.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$298.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$298.43
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$246.62
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Bexsero Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
5216616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTap Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTap Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTap Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
3013447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$44.89 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.89
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$31.61
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Dtap-Hep B-IPV Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
3912011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$186.67 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$186.67
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$107.76
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
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 |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
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 |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTaP-IPV Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTaP-IPV Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - DTaP-IPV Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
3013468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$112.15 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| 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 |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$67.15
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Hep A Pediatric Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
3013459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$59.68 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| 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 |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: United Healthcare Medicaid |
$41.59
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
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 |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
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 |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Hep B Ped/Adol Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
2588800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$86.32 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$34.53
|
| Rate for Payer: Anthem Medicare Advantage |
$34.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34.53
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| 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 |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| 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 |
$34.53
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$51.79
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$34.53
|
| Rate for Payer: The Alliance Commercial |
$86.32
|
| Rate for Payer: United Healthcare Medicaid |
$30.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.53
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
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 |
$6.41 |
| Max. Negotiated Rate |
$138.11 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.34
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$138.11
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
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 |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
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 |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
State Supplied - Hep B (Recombivax) Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90744
|
| Hospital Charge Code |
3947958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$86.32 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$34.53
|
| Rate for Payer: Anthem Medicare Advantage |
$34.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34.53
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| 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 |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| 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 |
$34.53
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$51.79
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$34.53
|
| Rate for Payer: The Alliance Commercial |
$86.32
|
| Rate for Payer: United Healthcare Medicaid |
$30.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.53
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
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 |
$6.41 |
| Max. Negotiated Rate |
$138.11 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.34
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$138.11
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
State Supplied - HIB Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
3013474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
