|
Pneuma/vac walk boot pre ots L4361
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
4498697
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$387.10 |
| Max. Negotiated Rate |
$726.80 |
| Rate for Payer: Aetna Commercial |
$711.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$679.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$418.70
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$726.80
|
| Rate for Payer: Health EOS Commercial |
$703.10
|
| Rate for Payer: HFN Commercial |
$726.80
|
| Rate for Payer: Multiplan Commercial |
$632.00
|
| Rate for Payer: NAPHCARE Commercial |
$474.00
|
| Rate for Payer: Preferred Network Access Commercial |
$726.80
|
| Rate for Payer: Quartz Beloit One Network |
$387.10
|
| Rate for Payer: Quartz Commercial |
$474.00
|
| Rate for Payer: WEA Trust Commercial |
$434.50
|
| Rate for Payer: WPS Commercial |
$585.15
|
|
|
Pneumococcal vaccine
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3353526
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Aetna Managed Medicare |
$28.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$176.58
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$65.00
|
| Rate for Payer: Quartz Medicare Advantage |
$60.00
|
| Rate for Payer: The Alliance Commercial |
$400.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$333.68
|
|
|
Pneumococcal vaccine
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3353526
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
Pneumococcal Vaccine
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3005584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
Pneumococcal Vaccine
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3005584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Aetna Managed Medicare |
$28.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$176.58
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$65.00
|
| Rate for Payer: Quartz Medicare Advantage |
$60.00
|
| Rate for Payer: The Alliance Commercial |
$400.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$333.68
|
|
|
Pneumococcal Vaccine 90732 man
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3369602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$744.00 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Aetna Managed Medicare |
$52.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$89.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$176.58
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$139.50
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$111.60
|
| Rate for Payer: The Alliance Commercial |
$744.00
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$333.68
|
|
|
Pneumococcal Vaccine 90732 man
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3369602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.14 |
| Max. Negotiated Rate |
$171.12 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$111.60
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Pneumococcal Vaccine 90732 man
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3369602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.84 |
| Max. Negotiated Rate |
$333.68 |
| Rate for Payer: Aetna Commercial |
$176.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$176.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.47
|
| Rate for Payer: Health EOS Commercial |
$169.26
|
| Rate for Payer: HFN Commercial |
$176.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$183.84
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$176.70
|
| Rate for Payer: Quartz Beloit One Network |
$81.84
|
| Rate for Payer: Quartz Commercial |
$106.02
|
| Rate for Payer: The Alliance Commercial |
$93.00
|
| Rate for Payer: United Healthcare Medicaid |
$132.08
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$333.68
|
|
|
Pneumococcal Vacc, Ped <5 13 Valent 90670
|
Professional
|
Both
|
$388.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3397516
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.72 |
| Max. Negotiated Rate |
$644.97 |
| Rate for Payer: Aetna Commercial |
$368.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.68
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$368.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$241.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.99
|
| Rate for Payer: Health EOS Commercial |
$353.08
|
| Rate for Payer: HFN Commercial |
$368.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$352.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$352.41
|
| Rate for Payer: Multiplan Commercial |
$310.40
|
| Rate for Payer: Preferred Network Access Commercial |
$368.60
|
| Rate for Payer: Quartz Beloit One Network |
$170.72
|
| Rate for Payer: Quartz Commercial |
$221.16
|
| Rate for Payer: The Alliance Commercial |
$194.00
|
| Rate for Payer: United Healthcare Medicaid |
$241.43
|
| Rate for Payer: WEA Trust Commercial |
$213.40
|
| Rate for Payer: WPS Commercial |
$644.97
|
|
|
Pneumococcal Vacc, Ped <5 13 Valent 90670
|
Facility
|
OP
|
$388.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3397516
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.64 |
| Max. Negotiated Rate |
$1,552.00 |
| Rate for Payer: Aetna Commercial |
$349.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.68
|
| Rate for Payer: Aetna Managed Medicare |
$108.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$194.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.64
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$356.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.32
|
| Rate for Payer: Health EOS Commercial |
$345.32
|
| Rate for Payer: HFN Commercial |
$356.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$291.00
|
| Rate for Payer: Multiplan Commercial |
$310.40
|
| Rate for Payer: NAPHCARE Commercial |
$232.80
|
| Rate for Payer: Preferred Network Access Commercial |
$356.96
|
| Rate for Payer: Quartz Beloit One Network |
$190.12
|
| Rate for Payer: Quartz Commercial |
$252.20
|
| Rate for Payer: Quartz Medicare Advantage |
$232.80
|
| Rate for Payer: The Alliance Commercial |
$1,552.00
|
| Rate for Payer: WEA Trust Commercial |
$213.40
|
| Rate for Payer: WPS Commercial |
$644.97
|
|
|
Pneumococcal Vacc, Ped <5 13 Valent 90670
|
Facility
|
IP
|
$388.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3397516
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$190.12 |
| Max. Negotiated Rate |
$356.96 |
| Rate for Payer: Aetna Commercial |
$349.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.64
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$356.96
|
| Rate for Payer: Health EOS Commercial |
$345.32
|
| Rate for Payer: HFN Commercial |
$356.96
|
| Rate for Payer: Multiplan Commercial |
$310.40
|
| Rate for Payer: NAPHCARE Commercial |
$232.80
|
| Rate for Payer: Preferred Network Access Commercial |
$356.96
|
| Rate for Payer: Quartz Beloit One Network |
$190.12
|
| Rate for Payer: Quartz Commercial |
$232.80
|
| Rate for Payer: WEA Trust Commercial |
$213.40
|
| Rate for Payer: WPS Commercial |
$287.39
|
|
|
Pneumococcal Vacc, Ped <5 13 Valent - 90670 VFC
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5905647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
Pneumococcal Vacc, Ped <5 13 Valent - 90670 VFC
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5905647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$644.97 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.32
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$644.97
|
|
|
Pneumococcal Vacc, Ped <5 13 Valent - 90670 VFC
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5905647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$644.97 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$241.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.99
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$352.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$352.41
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$241.43
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$644.97
|
|
|
Pneumococcal valent 13
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5621732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.96 |
| Max. Negotiated Rate |
$1,828.00 |
| Rate for Payer: Aetna Commercial |
$411.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.02
|
| Rate for Payer: Aetna Managed Medicare |
$127.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.21
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$420.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.32
|
| Rate for Payer: Health EOS Commercial |
$406.73
|
| Rate for Payer: HFN Commercial |
$420.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$342.75
|
| Rate for Payer: Multiplan Commercial |
$365.60
|
| Rate for Payer: NAPHCARE Commercial |
$274.20
|
| Rate for Payer: Preferred Network Access Commercial |
$420.44
|
| Rate for Payer: Quartz Beloit One Network |
$223.93
|
| Rate for Payer: Quartz Commercial |
$297.05
|
| Rate for Payer: Quartz Medicare Advantage |
$274.20
|
| Rate for Payer: The Alliance Commercial |
$1,828.00
|
| Rate for Payer: WEA Trust Commercial |
$251.35
|
| Rate for Payer: WPS Commercial |
$644.97
|
|
|
Pneumococcal valent 13
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5621732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$223.93 |
| Max. Negotiated Rate |
$420.44 |
| Rate for Payer: Aetna Commercial |
$411.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.21
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$420.44
|
| Rate for Payer: Health EOS Commercial |
$406.73
|
| Rate for Payer: HFN Commercial |
$420.44
|
| Rate for Payer: Multiplan Commercial |
$365.60
|
| Rate for Payer: NAPHCARE Commercial |
$274.20
|
| Rate for Payer: Preferred Network Access Commercial |
$420.44
|
| Rate for Payer: Quartz Beloit One Network |
$223.93
|
| Rate for Payer: Quartz Commercial |
$274.20
|
| Rate for Payer: WEA Trust Commercial |
$251.35
|
| Rate for Payer: WPS Commercial |
$338.50
|
|
|
Pneumococcal valent13
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5621737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$223.93 |
| Max. Negotiated Rate |
$420.44 |
| Rate for Payer: Aetna Commercial |
$411.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.21
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$420.44
|
| Rate for Payer: Health EOS Commercial |
$406.73
|
| Rate for Payer: HFN Commercial |
$420.44
|
| Rate for Payer: Multiplan Commercial |
$365.60
|
| Rate for Payer: NAPHCARE Commercial |
$274.20
|
| Rate for Payer: Preferred Network Access Commercial |
$420.44
|
| Rate for Payer: Quartz Beloit One Network |
$223.93
|
| Rate for Payer: Quartz Commercial |
$274.20
|
| Rate for Payer: WEA Trust Commercial |
$251.35
|
| Rate for Payer: WPS Commercial |
$338.50
|
|
|
Pneumococcal valent13
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5621737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.96 |
| Max. Negotiated Rate |
$1,828.00 |
| Rate for Payer: Aetna Commercial |
$411.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.02
|
| Rate for Payer: Aetna Managed Medicare |
$127.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.21
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$420.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.32
|
| Rate for Payer: Health EOS Commercial |
$406.73
|
| Rate for Payer: HFN Commercial |
$420.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$342.75
|
| Rate for Payer: Multiplan Commercial |
$365.60
|
| Rate for Payer: NAPHCARE Commercial |
$274.20
|
| Rate for Payer: Preferred Network Access Commercial |
$420.44
|
| Rate for Payer: Quartz Beloit One Network |
$223.93
|
| Rate for Payer: Quartz Commercial |
$297.05
|
| Rate for Payer: Quartz Medicare Advantage |
$274.20
|
| Rate for Payer: The Alliance Commercial |
$1,828.00
|
| Rate for Payer: WEA Trust Commercial |
$251.35
|
| Rate for Payer: WPS Commercial |
$644.97
|
|
|
Pneumococcal valent 20
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$261.17 |
| Max. Negotiated Rate |
$490.36 |
| Rate for Payer: Aetna Commercial |
$479.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$458.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$282.49
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$490.36
|
| Rate for Payer: Health EOS Commercial |
$474.37
|
| Rate for Payer: HFN Commercial |
$490.36
|
| Rate for Payer: Multiplan Commercial |
$426.40
|
| Rate for Payer: NAPHCARE Commercial |
$319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.36
|
| Rate for Payer: Quartz Beloit One Network |
$261.17
|
| Rate for Payer: Quartz Commercial |
$319.80
|
| Rate for Payer: WEA Trust Commercial |
$293.15
|
| Rate for Payer: WPS Commercial |
$394.79
|
|
|
Pneumococcal valent 20
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.24 |
| Max. Negotiated Rate |
$2,132.00 |
| Rate for Payer: Aetna Commercial |
$479.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$458.38
|
| Rate for Payer: Aetna Managed Medicare |
$149.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$346.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$266.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$282.49
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$490.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.30
|
| Rate for Payer: Health EOS Commercial |
$474.37
|
| Rate for Payer: HFN Commercial |
$490.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$399.75
|
| Rate for Payer: Multiplan Commercial |
$426.40
|
| Rate for Payer: NAPHCARE Commercial |
$319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.36
|
| Rate for Payer: Quartz Beloit One Network |
$261.17
|
| Rate for Payer: Quartz Commercial |
$346.45
|
| Rate for Payer: Quartz Medicare Advantage |
$319.80
|
| Rate for Payer: The Alliance Commercial |
$2,132.00
|
| Rate for Payer: WEA Trust Commercial |
$293.15
|
| Rate for Payer: WPS Commercial |
$745.09
|
|
|
Pneumococcal valent 20
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.24 |
| Max. Negotiated Rate |
$2,132.00 |
| Rate for Payer: Aetna Commercial |
$479.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$458.38
|
| Rate for Payer: Aetna Managed Medicare |
$149.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$346.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$266.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$282.49
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$490.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.30
|
| Rate for Payer: Health EOS Commercial |
$474.37
|
| Rate for Payer: HFN Commercial |
$490.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$399.75
|
| Rate for Payer: Multiplan Commercial |
$426.40
|
| Rate for Payer: NAPHCARE Commercial |
$319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.36
|
| Rate for Payer: Quartz Beloit One Network |
$261.17
|
| Rate for Payer: Quartz Commercial |
$346.45
|
| Rate for Payer: Quartz Medicare Advantage |
$319.80
|
| Rate for Payer: The Alliance Commercial |
$2,132.00
|
| Rate for Payer: WEA Trust Commercial |
$293.15
|
| Rate for Payer: WPS Commercial |
$745.09
|
|
|
Pneumococcal valent 20
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$261.17 |
| Max. Negotiated Rate |
$490.36 |
| Rate for Payer: Aetna Commercial |
$479.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$458.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$282.49
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$490.36
|
| Rate for Payer: Health EOS Commercial |
$474.37
|
| Rate for Payer: HFN Commercial |
$490.36
|
| Rate for Payer: Multiplan Commercial |
$426.40
|
| Rate for Payer: NAPHCARE Commercial |
$319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.36
|
| Rate for Payer: Quartz Beloit One Network |
$261.17
|
| Rate for Payer: Quartz Commercial |
$319.80
|
| Rate for Payer: WEA Trust Commercial |
$293.15
|
| Rate for Payer: WPS Commercial |
$394.79
|
|
|
PNEUMOTHORAX WITH CC
|
Facility
|
IP
|
$28,954.00
|
|
|
Service Code
|
MSDRG 200
|
| Min. Negotiated Rate |
$10,414.94 |
| Max. Negotiated Rate |
$28,954.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,414.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,367.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,500.24
|
| Rate for Payer: Anthem Medicare Advantage |
$10,414.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,414.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,414.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,414.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,316.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,414.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,001.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,414.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,414.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,414.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,414.94
|
| Rate for Payer: NAPHCARE Commercial |
$15,622.41
|
| Rate for Payer: Quartz Medicare Advantage |
$10,414.94
|
| Rate for Payer: The Alliance Commercial |
$28,954.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,414.94
|
| Rate for Payer: United Healthcare PPO |
$16,349.94
|
| Rate for Payer: Wellcare Medicare |
$10,414.94
|
|
|
PNEUMOTHORAX WITH MCC
|
Facility
|
IP
|
$47,487.00
|
|
|
Service Code
|
MSDRG 199
|
| Min. Negotiated Rate |
$17,081.52 |
| Max. Negotiated Rate |
$47,487.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,081.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37,134.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,463.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,042.06
|
| Rate for Payer: Anthem Medicare Advantage |
$17,081.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,081.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,081.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,081.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,019.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,081.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,594.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,081.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,081.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,081.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,081.52
|
| Rate for Payer: NAPHCARE Commercial |
$25,622.28
|
| Rate for Payer: Quartz Medicare Advantage |
$17,081.52
|
| Rate for Payer: The Alliance Commercial |
$47,487.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,081.52
|
| Rate for Payer: United Healthcare PPO |
$26,932.61
|
| Rate for Payer: Wellcare Medicare |
$17,081.52
|
|
|
PNEUMOTHORAX WITHOUT CC/MCC
|
Facility
|
IP
|
$19,093.00
|
|
|
Service Code
|
MSDRG 201
|
| Min. Negotiated Rate |
$6,867.90 |
| Max. Negotiated Rate |
$19,093.00 |
| Rate for Payer: Aetna Managed Medicare |
$6,867.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,895.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,417.51
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,847.38
|
| Rate for Payer: Anthem Medicare Advantage |
$6,867.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,867.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,867.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,867.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,041.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,867.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,768.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,867.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,867.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,867.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,867.90
|
| Rate for Payer: NAPHCARE Commercial |
$10,301.85
|
| Rate for Payer: Quartz Medicare Advantage |
$6,867.90
|
| Rate for Payer: The Alliance Commercial |
$19,093.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,867.90
|
| Rate for Payer: United Healthcare PPO |
$10,719.30
|
| Rate for Payer: Wellcare Medicare |
$6,867.90
|
|
