|
Pneumococcal vaccine
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3353526
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$555.24 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$29.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$183.64
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$62.40
|
| Rate for Payer: The Alliance Commercial |
$555.24
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$347.03
|
|
|
Pneumococcal vaccine
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3353526
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
Pneumococcal Vaccine
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3005584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$555.24 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$29.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$183.64
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$62.40
|
| Rate for Payer: The Alliance Commercial |
$555.24
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$347.03
|
|
|
Pneumococcal Vaccine
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3005584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
Pneumococcal Vaccine 90732 man
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3369602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.16 |
| Max. Negotiated Rate |
$555.24 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Aetna Managed Medicare |
$54.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$183.64
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.08
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: NAPHCARE Commercial |
$116.06
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$125.74
|
| Rate for Payer: Quartz Medicare Advantage |
$116.06
|
| Rate for Payer: The Alliance Commercial |
$555.24
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$347.03
|
|
|
Pneumococcal Vaccine 90732 man
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3369602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.79 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$116.06
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Pneumococcal Vaccine 90732 man
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3369602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.11 |
| Max. Negotiated Rate |
$347.03 |
| Rate for Payer: Aetna Commercial |
$183.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Aetna Managed Medicare |
$138.81
|
| Rate for Payer: Anthem Medicare Advantage |
$138.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$138.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$138.81
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$183.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.81
|
| Rate for Payer: Health EOS Commercial |
$176.03
|
| Rate for Payer: HFN Commercial |
$183.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$191.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$138.81
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: NAPHCARE Commercial |
$208.21
|
| Rate for Payer: Preferred Network Access Commercial |
$183.77
|
| Rate for Payer: Quartz Beloit One Network |
$85.11
|
| Rate for Payer: Quartz Commercial |
$110.26
|
| Rate for Payer: Quartz Medicare Advantage |
$138.81
|
| Rate for Payer: The Alliance Commercial |
$347.02
|
| Rate for Payer: United Healthcare Medicaid |
$121.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$138.81
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$347.03
|
|
|
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 |
$177.55 |
| Max. Negotiated Rate |
$670.77 |
| Rate for Payer: Aetna Commercial |
$383.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.03
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$383.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$201.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.31
|
| Rate for Payer: Health EOS Commercial |
$367.20
|
| Rate for Payer: HFN Commercial |
$383.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$366.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$366.51
|
| Rate for Payer: Multiplan Commercial |
$322.82
|
| Rate for Payer: Preferred Network Access Commercial |
$383.34
|
| Rate for Payer: Quartz Beloit One Network |
$177.55
|
| Rate for Payer: Quartz Commercial |
$230.01
|
| Rate for Payer: The Alliance Commercial |
$201.76
|
| Rate for Payer: WEA Trust Commercial |
$221.94
|
| Rate for Payer: WPS Commercial |
$670.77
|
|
|
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 |
$112.99 |
| Max. Negotiated Rate |
$670.77 |
| Rate for Payer: Aetna Commercial |
$363.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.03
|
| Rate for Payer: Aetna Managed Medicare |
$112.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$262.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$201.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$193.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.87
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$371.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$359.13
|
| Rate for Payer: HFN Commercial |
$371.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$302.64
|
| Rate for Payer: Multiplan Commercial |
$322.82
|
| Rate for Payer: NAPHCARE Commercial |
$242.11
|
| Rate for Payer: Preferred Network Access Commercial |
$371.24
|
| Rate for Payer: Quartz Beloit One Network |
$197.72
|
| Rate for Payer: Quartz Commercial |
$262.29
|
| Rate for Payer: Quartz Medicare Advantage |
$242.11
|
| Rate for Payer: The Alliance Commercial |
$201.76
|
| Rate for Payer: WEA Trust Commercial |
$221.94
|
| Rate for Payer: WPS Commercial |
$670.77
|
|
|
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 |
$197.72 |
| Max. Negotiated Rate |
$371.24 |
| Rate for Payer: Aetna Commercial |
$363.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.87
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$371.24
|
| Rate for Payer: Health EOS Commercial |
$359.13
|
| Rate for Payer: HFN Commercial |
$371.24
|
| Rate for Payer: Multiplan Commercial |
$322.82
|
| Rate for Payer: Preferred Network Access Commercial |
$371.24
|
| Rate for Payer: Quartz Beloit One Network |
$197.72
|
| Rate for Payer: Quartz Commercial |
$242.11
|
| Rate for Payer: WEA Trust Commercial |
$221.94
|
| Rate for Payer: WPS Commercial |
$298.88
|
|
|
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 |
$9.53 |
| Max. Negotiated Rate |
$670.77 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.31
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$366.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$366.51
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$670.77
|
|
|
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 |
$10.61 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$6.07 |
| Max. Negotiated Rate |
$670.77 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$670.77
|
|
|
Pneumococcal valent13
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5621737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$232.89 |
| Max. Negotiated Rate |
$437.26 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$285.17
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
|
Pneumococcal valent13
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5621737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.08 |
| Max. Negotiated Rate |
$670.77 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Aetna Managed Medicare |
$133.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$308.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$237.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$228.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$356.46
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: NAPHCARE Commercial |
$285.17
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$308.93
|
| Rate for Payer: Quartz Medicare Advantage |
$285.17
|
| Rate for Payer: The Alliance Commercial |
$237.64
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$670.77
|
|
|
Pneumococcal valent 13
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5621732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.08 |
| Max. Negotiated Rate |
$670.77 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Aetna Managed Medicare |
$133.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$308.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$237.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$228.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$356.46
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: NAPHCARE Commercial |
$285.17
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$308.93
|
| Rate for Payer: Quartz Medicare Advantage |
$285.17
|
| Rate for Payer: The Alliance Commercial |
$237.64
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$670.77
|
|
|
Pneumococcal valent 13
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
5621732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$232.89 |
| Max. Negotiated Rate |
$437.26 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$285.17
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
|
Pneumococcal valent 20
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.62 |
| Max. Negotiated Rate |
$509.97 |
| Rate for Payer: Aetna Commercial |
$498.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$476.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.79
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$509.97
|
| Rate for Payer: Health EOS Commercial |
$493.34
|
| Rate for Payer: HFN Commercial |
$509.97
|
| Rate for Payer: Multiplan Commercial |
$443.46
|
| Rate for Payer: Preferred Network Access Commercial |
$509.97
|
| Rate for Payer: Quartz Beloit One Network |
$271.62
|
| Rate for Payer: Quartz Commercial |
$332.59
|
| Rate for Payer: WEA Trust Commercial |
$304.88
|
| Rate for Payer: WPS Commercial |
$410.57
|
|
|
Pneumococcal valent 20
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.21 |
| Max. Negotiated Rate |
$1,418.56 |
| Rate for Payer: Aetna Commercial |
$498.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$476.72
|
| Rate for Payer: Aetna Managed Medicare |
$155.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$360.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$277.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.79
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$509.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.07
|
| Rate for Payer: Health EOS Commercial |
$493.34
|
| Rate for Payer: HFN Commercial |
$509.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$415.74
|
| Rate for Payer: Multiplan Commercial |
$443.46
|
| Rate for Payer: NAPHCARE Commercial |
$332.59
|
| Rate for Payer: Preferred Network Access Commercial |
$509.97
|
| Rate for Payer: Quartz Beloit One Network |
$271.62
|
| Rate for Payer: Quartz Commercial |
$360.31
|
| Rate for Payer: Quartz Medicare Advantage |
$332.59
|
| Rate for Payer: The Alliance Commercial |
$1,418.56
|
| Rate for Payer: WEA Trust Commercial |
$304.88
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
Pneumococcal valent 20
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.21 |
| Max. Negotiated Rate |
$1,418.56 |
| Rate for Payer: Aetna Commercial |
$498.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$476.72
|
| Rate for Payer: Aetna Managed Medicare |
$155.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$360.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$277.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.79
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$509.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.07
|
| Rate for Payer: Health EOS Commercial |
$493.34
|
| Rate for Payer: HFN Commercial |
$509.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$415.74
|
| Rate for Payer: Multiplan Commercial |
$443.46
|
| Rate for Payer: NAPHCARE Commercial |
$332.59
|
| Rate for Payer: Preferred Network Access Commercial |
$509.97
|
| Rate for Payer: Quartz Beloit One Network |
$271.62
|
| Rate for Payer: Quartz Commercial |
$360.31
|
| Rate for Payer: Quartz Medicare Advantage |
$332.59
|
| Rate for Payer: The Alliance Commercial |
$1,418.56
|
| Rate for Payer: WEA Trust Commercial |
$304.88
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
Pneumococcal valent 20
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.62 |
| Max. Negotiated Rate |
$509.97 |
| Rate for Payer: Aetna Commercial |
$498.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$476.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.79
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$509.97
|
| Rate for Payer: Health EOS Commercial |
$493.34
|
| Rate for Payer: HFN Commercial |
$509.97
|
| Rate for Payer: Multiplan Commercial |
$443.46
|
| Rate for Payer: Preferred Network Access Commercial |
$509.97
|
| Rate for Payer: Quartz Beloit One Network |
$271.62
|
| Rate for Payer: Quartz Commercial |
$332.59
|
| Rate for Payer: WEA Trust Commercial |
$304.88
|
| Rate for Payer: WPS Commercial |
$410.57
|
|
|
PNEUMOTHORAX WITH CC
|
Facility
|
IP
|
$30,112.16
|
|
|
Service Code
|
MSDRG 200
|
| Min. Negotiated Rate |
$8,925.44 |
| Max. Negotiated Rate |
$30,112.16 |
| Rate for Payer: Aetna Managed Medicare |
$8,925.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,985.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,384.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,466.91
|
| Rate for Payer: Anthem Medicare Advantage |
$8,925.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,925.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,925.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,925.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,389.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,925.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,841.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,925.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,925.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,925.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,925.44
|
| Rate for Payer: NAPHCARE Commercial |
$13,388.15
|
| Rate for Payer: Quartz Medicare Advantage |
$8,925.44
|
| Rate for Payer: The Alliance Commercial |
$30,112.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,925.44
|
| Rate for Payer: United Healthcare PPO |
$17,003.94
|
| Rate for Payer: Wellcare Medicare |
$8,925.44
|
|
|
PNEUMOTHORAX WITH MCC
|
Facility
|
IP
|
$49,386.48
|
|
|
Service Code
|
MSDRG 199
|
| Min. Negotiated Rate |
$14,016.61 |
| Max. Negotiated Rate |
$49,386.48 |
| Rate for Payer: Aetna Managed Medicare |
$14,016.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,491.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,503.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,030.00
|
| Rate for Payer: Anthem Medicare Advantage |
$14,016.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,016.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,016.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,016.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,115.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,016.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35,978.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,016.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,016.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,016.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,016.61
|
| Rate for Payer: NAPHCARE Commercial |
$21,024.92
|
| Rate for Payer: Quartz Medicare Advantage |
$14,016.61
|
| Rate for Payer: The Alliance Commercial |
$49,386.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,016.61
|
| Rate for Payer: United Healthcare PPO |
$28,009.91
|
| Rate for Payer: Wellcare Medicare |
$14,016.61
|
|
|
PNEUMOTHORAX WITHOUT CC/MCC
|
Facility
|
IP
|
$19,856.72
|
|
|
Service Code
|
MSDRG 201
|
| Min. Negotiated Rate |
$5,983.16 |
| Max. Negotiated Rate |
$19,856.72 |
| Rate for Payer: Aetna Managed Medicare |
$5,983.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,602.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,959.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,362.31
|
| Rate for Payer: Anthem Medicare Advantage |
$5,983.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,983.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,983.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,983.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,613.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,983.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,319.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,983.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,983.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,983.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,983.16
|
| Rate for Payer: NAPHCARE Commercial |
$8,974.74
|
| Rate for Payer: Quartz Medicare Advantage |
$5,983.16
|
| Rate for Payer: The Alliance Commercial |
$19,856.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,983.16
|
| Rate for Payer: United Healthcare PPO |
$11,148.07
|
| Rate for Payer: Wellcare Medicare |
$5,983.16
|
|
|
Pneumovax Supplies
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
3005585
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$15.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.85
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.34
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$33.07
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$35.83
|
| Rate for Payer: Quartz Medicare Advantage |
$33.07
|
| Rate for Payer: The Alliance Commercial |
$27.56
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
