|
Administered - Metoclopramide Charge
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
3983494
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Administered - Metoclopramide Charge
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
3983494
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$595.32 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.38
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$595.32
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$2.60
|
|
|
Administered - Metoclopramide Charge
|
Professional
|
$7.00
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
3983494
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.24
|
| Rate for Payer: Anthem Medicare Advantage |
$1.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.24
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.04
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: Quartz Medicare Advantage |
$1.24
|
| Rate for Payer: The Alliance Commercial |
$3.40
|
| Rate for Payer: United Healthcare Medicaid |
$1.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.24
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$2.60
|
|
|
Administered - Rabies Charge
|
Professional
|
$643.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3013491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$275.23 |
| Max. Negotiated Rate |
$824.97 |
| Rate for Payer: Aetna Commercial |
$610.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.98
|
| Rate for Payer: Aetna Managed Medicare |
$329.99
|
| Rate for Payer: Anthem Medicare Advantage |
$329.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$329.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$329.99
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$610.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$321.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$322.76
|
| Rate for Payer: Health EOS Commercial |
$585.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$506.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$506.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$329.99
|
| Rate for Payer: Multiplan Commercial |
$514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$610.85
|
| Rate for Payer: Quartz Beloit One Network |
$282.92
|
| Rate for Payer: Quartz Commercial |
$366.51
|
| Rate for Payer: Quartz Medicare Advantage |
$329.99
|
| Rate for Payer: The Alliance Commercial |
$824.97
|
| Rate for Payer: United Healthcare Medicaid |
$275.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$329.99
|
| Rate for Payer: WEA Trust Commercial |
$353.65
|
| Rate for Payer: WPS Commercial |
$806.91
|
|
|
Administered - Rabies Charge
|
Facility
OP
|
$643.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3013491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$308.64 |
| Max. Negotiated Rate |
$1,208.05 |
| Rate for Payer: Aetna Commercial |
$578.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.98
|
| Rate for Payer: Aetna Managed Medicare |
$324.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$417.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$321.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$308.64
|
| Rate for Payer: Anthem Medicare Advantage |
$324.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$324.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$324.74
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$591.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$324.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$427.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$324.74
|
| Rate for Payer: Health EOS Commercial |
$572.27
|
| Rate for Payer: HFN Commercial |
$591.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,208.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$324.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$324.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$324.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$324.74
|
| Rate for Payer: Multiplan Commercial |
$514.40
|
| Rate for Payer: NAPHCARE Commercial |
$487.12
|
| Rate for Payer: Preferred Network Access Commercial |
$591.56
|
| Rate for Payer: Quartz Beloit One Network |
$315.07
|
| Rate for Payer: Quartz Commercial |
$417.95
|
| Rate for Payer: Quartz Medicare Advantage |
$324.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$324.74
|
| Rate for Payer: WEA Trust Commercial |
$353.65
|
| Rate for Payer: Wellcare Medicare |
$324.74
|
| Rate for Payer: WPS Commercial |
$806.91
|
|
|
Administered - Rabies Charge
|
Facility
IP
|
$643.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3013491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$315.07 |
| Max. Negotiated Rate |
$591.56 |
| Rate for Payer: Aetna Commercial |
$578.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.79
|
| Rate for Payer: Cash Price |
$192.90
|
| Rate for Payer: Cigna Commercial |
$591.56
|
| Rate for Payer: Health EOS Commercial |
$572.27
|
| Rate for Payer: HFN Commercial |
$591.56
|
| Rate for Payer: Multiplan Commercial |
$514.40
|
| Rate for Payer: NAPHCARE Commercial |
$385.80
|
| Rate for Payer: Preferred Network Access Commercial |
$591.56
|
| Rate for Payer: Quartz Beloit One Network |
$315.07
|
| Rate for Payer: Quartz Commercial |
$385.80
|
| Rate for Payer: WEA Trust Commercial |
$353.65
|
| Rate for Payer: WPS Commercial |
$476.27
|
|
|
Administered - Shingrix Charge
|
Facility
IP
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5394637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$312.80 |
| Rate for Payer: Aetna Commercial |
$306.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.20
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$312.80
|
| Rate for Payer: Health EOS Commercial |
$302.60
|
| Rate for Payer: HFN Commercial |
$312.80
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: NAPHCARE Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$312.80
|
| Rate for Payer: Quartz Beloit One Network |
$166.60
|
| Rate for Payer: Quartz Commercial |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Administered - Shingrix Charge
|
Facility
OP
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5394637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$1,360.00 |
| Rate for Payer: Aetna Commercial |
$306.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Aetna Managed Medicare |
$95.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$221.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$170.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$163.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.20
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$312.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.26
|
| Rate for Payer: Health EOS Commercial |
$302.60
|
| Rate for Payer: HFN Commercial |
$312.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$255.00
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: NAPHCARE Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$312.80
|
| Rate for Payer: Quartz Beloit One Network |
$166.60
|
| Rate for Payer: Quartz Commercial |
$221.00
|
| Rate for Payer: Quartz Medicare Advantage |
$204.00
|
| Rate for Payer: The Alliance Commercial |
$1,360.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Administered - Shingrix Charge
|
Professional
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5394637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.60 |
| Max. Negotiated Rate |
$323.00 |
| Rate for Payer: Aetna Commercial |
$323.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$170.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$204.00
|
| Rate for Payer: Health EOS Commercial |
$309.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$242.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.45
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: Preferred Network Access Commercial |
$323.00
|
| Rate for Payer: Quartz Beloit One Network |
$149.60
|
| Rate for Payer: Quartz Commercial |
$193.80
|
| Rate for Payer: The Alliance Commercial |
$170.00
|
| Rate for Payer: United Healthcare Medicaid |
$198.41
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Administered - Typhoid Charge
|
Professional
|
$194.00
|
|
|
Service Code
|
CPT 90691
|
| Hospital Charge Code |
3013492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.87 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna Commercial |
$184.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$184.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$97.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$176.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$180.57
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: Preferred Network Access Commercial |
$184.30
|
| Rate for Payer: Quartz Beloit One Network |
$85.36
|
| Rate for Payer: Quartz Commercial |
$110.58
|
| Rate for Payer: The Alliance Commercial |
$97.00
|
| Rate for Payer: United Healthcare Medicaid |
$82.87
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
Administered - Typhoid Charge
|
Facility
IP
|
$194.00
|
|
|
Service Code
|
CPT 90691
|
| Hospital Charge Code |
3013492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
Administered - Typhoid Charge
|
Facility
OP
|
$194.00
|
|
|
Service Code
|
CPT 90691
|
| Hospital Charge Code |
3013492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.50
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
Administered - Zostavax Charge
|
Facility
IP
|
$484.00
|
|
|
Service Code
|
CPT 90736
|
| Hospital Charge Code |
3013483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$237.16 |
| Max. Negotiated Rate |
$445.28 |
| Rate for Payer: Aetna Commercial |
$435.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$256.52
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$445.28
|
| Rate for Payer: Health EOS Commercial |
$430.76
|
| Rate for Payer: HFN Commercial |
$445.28
|
| Rate for Payer: Multiplan Commercial |
$387.20
|
| Rate for Payer: NAPHCARE Commercial |
$290.40
|
| Rate for Payer: Preferred Network Access Commercial |
$445.28
|
| Rate for Payer: Quartz Beloit One Network |
$237.16
|
| Rate for Payer: Quartz Commercial |
$290.40
|
| Rate for Payer: WEA Trust Commercial |
$266.20
|
| Rate for Payer: WPS Commercial |
$358.50
|
|
|
Administered - Zostavax Charge
|
Facility
OP
|
$484.00
|
|
|
Service Code
|
CPT 90736
|
| Hospital Charge Code |
3013483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$135.52 |
| Max. Negotiated Rate |
$1,936.00 |
| Rate for Payer: Aetna Commercial |
$435.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$416.24
|
| Rate for Payer: Aetna Managed Medicare |
$135.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$314.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$242.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$232.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$256.52
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$445.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$270.85
|
| Rate for Payer: Health EOS Commercial |
$430.76
|
| Rate for Payer: HFN Commercial |
$445.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$363.00
|
| Rate for Payer: Multiplan Commercial |
$387.20
|
| Rate for Payer: NAPHCARE Commercial |
$290.40
|
| Rate for Payer: Preferred Network Access Commercial |
$445.28
|
| Rate for Payer: Quartz Beloit One Network |
$237.16
|
| Rate for Payer: Quartz Commercial |
$314.60
|
| Rate for Payer: Quartz Medicare Advantage |
$290.40
|
| Rate for Payer: The Alliance Commercial |
$1,936.00
|
| Rate for Payer: WEA Trust Commercial |
$266.20
|
| Rate for Payer: WPS Commercial |
$358.50
|
|
|
Administered - Zostavax Charge
|
Professional
|
$484.00
|
|
|
Service Code
|
CPT 90736
|
| Hospital Charge Code |
3013483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.69 |
| Max. Negotiated Rate |
$459.80 |
| Rate for Payer: Aetna Commercial |
$459.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$416.24
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$459.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$242.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$290.40
|
| Rate for Payer: Health EOS Commercial |
$440.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$353.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$353.96
|
| Rate for Payer: Multiplan Commercial |
$387.20
|
| Rate for Payer: Preferred Network Access Commercial |
$459.80
|
| Rate for Payer: Quartz Beloit One Network |
$212.96
|
| Rate for Payer: Quartz Commercial |
$275.88
|
| Rate for Payer: The Alliance Commercial |
$242.00
|
| Rate for Payer: United Healthcare Medicaid |
$180.69
|
| Rate for Payer: WEA Trust Commercial |
$266.20
|
| Rate for Payer: WPS Commercial |
$358.50
|
|
|
Admin pneumococcal vaccine G0009
|
Professional
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3408191
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$57.26 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.40
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.26
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Admin pneumococcal vaccine G0009
|
Facility
OP
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3408191
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$268.48 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.95
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46.95
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$46.95
|
| Rate for Payer: The Alliance Commercial |
$268.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.95
|
| Rate for Payer: United Healthcare PPO |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Admin pneumococcal vaccine G0009
|
Facility
IP
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3408191
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Admin Pneumo Vaccine (Per Dialysis Com Ins)
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5622232
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$24.96 |
| Max. Negotiated Rate |
$259.02 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.96
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$33.80
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Admin Pneumo Vaccine (Per Dialysis Com Ins)
|
Facility
IP
|
$52.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5622232
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$31.20
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Admin Pneumo Vaccine (Per Dialysis Medicare/MADV)
|
Facility
IP
|
$52.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
5622233
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$31.20
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Admin Pneumo Vaccine (Per Dialysis Medicare/MADV)
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
5622233
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$24.96 |
| Max. Negotiated Rate |
$268.48 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.96
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.95
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46.95
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$33.80
|
| Rate for Payer: Quartz Medicare Advantage |
$46.95
|
| Rate for Payer: The Alliance Commercial |
$268.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.95
|
| Rate for Payer: United Healthcare PPO |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Admin Pneum Vaccine (Dialysis Com Ins)
|
Facility
IP
|
$52.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5622230
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$31.20
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Admin Pneum Vaccine (Dialysis Com Ins)
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
5622230
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$24.96 |
| Max. Negotiated Rate |
$259.02 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.96
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$33.80
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Admin Pneum Vaccine (Dialysis Medicare/MADV)
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
5622231
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$24.96 |
| Max. Negotiated Rate |
$268.48 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.96
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.95
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46.95
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$33.80
|
| Rate for Payer: Quartz Medicare Advantage |
$46.95
|
| Rate for Payer: The Alliance Commercial |
$268.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.95
|
| Rate for Payer: United Healthcare PPO |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
