|
Flu Virus Fluzone 90686
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.23
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Flu Virus Fluzone 90686
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$58.11 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.24
|
| Rate for Payer: Health EOS Commercial |
$17.04
|
| Rate for Payer: HFN Commercial |
$17.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.73
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.78
|
| Rate for Payer: Quartz Beloit One Network |
$8.24
|
| Rate for Payer: Quartz Commercial |
$10.67
|
| Rate for Payer: The Alliance Commercial |
$9.36
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$58.11
|
|
|
Flu Virus Fluzone 90686
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$58.11 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$5.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.75
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.04
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$11.23
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$12.17
|
| Rate for Payer: Quartz Medicare Advantage |
$11.23
|
| Rate for Payer: The Alliance Commercial |
$6.55
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$58.11
|
|
|
Flu Virus Fluzone 90687
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
CPT 90687
|
| Hospital Charge Code |
5470720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$5.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.36
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.04
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$11.23
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$12.17
|
| Rate for Payer: Quartz Medicare Advantage |
$11.23
|
| Rate for Payer: The Alliance Commercial |
$6.55
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$27.14
|
|
|
Flu Virus Fluzone 90687
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
CPT 90687
|
| Hospital Charge Code |
5470720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.23
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Flu Virus Fluzone 90687
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
CPT 90687
|
| Hospital Charge Code |
5470720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.86
|
| Rate for Payer: Health EOS Commercial |
$17.04
|
| Rate for Payer: HFN Commercial |
$17.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.55
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.78
|
| Rate for Payer: Quartz Beloit One Network |
$8.24
|
| Rate for Payer: Quartz Commercial |
$10.67
|
| Rate for Payer: The Alliance Commercial |
$9.36
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$27.14
|
|
|
Flu Virus Fluzone High Dose 90662
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
5472698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.96 |
| Max. Negotiated Rate |
$255.22 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$102.09
|
| Rate for Payer: Anthem Medicare Advantage |
$102.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$102.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$102.09
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$47.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.34
|
| Rate for Payer: Health EOS Commercial |
$45.43
|
| Rate for Payer: HFN Commercial |
$47.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$92.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$102.09
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$153.13
|
| Rate for Payer: Preferred Network Access Commercial |
$47.42
|
| Rate for Payer: Quartz Beloit One Network |
$21.96
|
| Rate for Payer: Quartz Commercial |
$28.45
|
| Rate for Payer: Quartz Medicare Advantage |
$102.09
|
| Rate for Payer: The Alliance Commercial |
$255.22
|
| Rate for Payer: United Healthcare Medicaid |
$89.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$102.09
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$190.85
|
|
|
Flu Virus Fluzone High Dose 90662
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
5472698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$408.35 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.00
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.44
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$32.45
|
| Rate for Payer: Quartz Medicare Advantage |
$29.95
|
| Rate for Payer: The Alliance Commercial |
$408.35
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$190.85
|
|
|
Flu Virus Fluzone High Dose 90662
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
5472698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$29.95
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Flu Virus VFC Flulaval 90686
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$58.11 |
| 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 |
$23.24
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.73
|
| 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 |
$58.11
|
|
|
Flu Virus VFC Flulaval 90686
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470724
|
|
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
|
|
|
Flu Virus VFC Flulaval 90686
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$58.11 |
| 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 |
$30.75
|
| 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 |
$7.58
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$58.11
|
|
|
Flu Virus VFC Fluzone 90685
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90685
|
| Hospital Charge Code |
5470722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$19.93 |
| 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: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| 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 |
$7.58
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
Flu Virus VFC Fluzone 90685
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90685
|
| Hospital Charge Code |
5470722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$32.08 |
| 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 |
$13.00
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.08
|
| 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 |
$16.05
|
|
|
Flu Virus VFC Fluzone 90685
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90685
|
| Hospital Charge Code |
5470722
|
|
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
|
|
|
Flu Virus VFC Fluzone 90686
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$58.11 |
| 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 |
$23.24
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.73
|
| 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 |
$58.11
|
|
|
Flu Virus VFC Fluzone 90686
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$58.11 |
| 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 |
$30.75
|
| 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 |
$7.58
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$58.11
|
|
|
Flu Virus VFC Fluzone 90686
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5470723
|
|
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
|
|
|
Fluvoxamine Level
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
5094645
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Aetna Managed Medicare |
$72.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$167.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$128.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$123.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.34
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.44
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: NAPHCARE Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$167.65
|
| Rate for Payer: Quartz Medicare Advantage |
$154.75
|
| Rate for Payer: The Alliance Commercial |
$128.96
|
| Rate for Payer: United Healthcare PPO |
$193.44
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
Fluvoxamine Level
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
5094645
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$245.02 |
| Rate for Payer: Aetna Commercial |
$245.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$245.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$128.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.75
|
| Rate for Payer: Health EOS Commercial |
$234.71
|
| Rate for Payer: HFN Commercial |
$245.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: Preferred Network Access Commercial |
$245.02
|
| Rate for Payer: Quartz Beloit One Network |
$113.48
|
| Rate for Payer: Quartz Commercial |
$147.01
|
| Rate for Payer: The Alliance Commercial |
$128.96
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
Fluvoxamine Level
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
5094645
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.38 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$154.75
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
Fluzone (0.50 ml dose) 90688
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
4356632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.20
|
| Rate for Payer: Aetna Managed Medicare |
$4.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.37
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$16.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.73
|
| Rate for Payer: Health EOS Commercial |
$15.74
|
| Rate for Payer: HFN Commercial |
$16.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.26
|
| Rate for Payer: Multiplan Commercial |
$14.14
|
| Rate for Payer: NAPHCARE Commercial |
$10.61
|
| Rate for Payer: Preferred Network Access Commercial |
$16.27
|
| Rate for Payer: Quartz Beloit One Network |
$8.66
|
| Rate for Payer: Quartz Commercial |
$11.49
|
| Rate for Payer: Quartz Medicare Advantage |
$10.61
|
| Rate for Payer: The Alliance Commercial |
$6.19
|
| Rate for Payer: WEA Trust Commercial |
$9.72
|
| Rate for Payer: WPS Commercial |
$54.28
|
|
|
Fluzone (0.50 ml dose) 90688
|
Professional
|
Both
|
$17.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
4356632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$16.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.20
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$16.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.71
|
| Rate for Payer: Health EOS Commercial |
$16.09
|
| Rate for Payer: HFN Commercial |
$16.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.11
|
| Rate for Payer: Multiplan Commercial |
$14.14
|
| Rate for Payer: Preferred Network Access Commercial |
$16.80
|
| Rate for Payer: Quartz Beloit One Network |
$7.78
|
| Rate for Payer: Quartz Commercial |
$10.08
|
| Rate for Payer: The Alliance Commercial |
$8.84
|
| Rate for Payer: WEA Trust Commercial |
$9.72
|
| Rate for Payer: WPS Commercial |
$54.28
|
|
|
Fluzone (0.50 ml dose) 90688
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
4356632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$16.27 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.37
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$16.27
|
| Rate for Payer: Health EOS Commercial |
$15.74
|
| Rate for Payer: HFN Commercial |
$16.27
|
| Rate for Payer: Multiplan Commercial |
$14.14
|
| Rate for Payer: Preferred Network Access Commercial |
$16.27
|
| Rate for Payer: Quartz Beloit One Network |
$8.66
|
| Rate for Payer: Quartz Commercial |
$10.61
|
| Rate for Payer: WEA Trust Commercial |
$9.72
|
| Rate for Payer: WPS Commercial |
$13.10
|
|
|
Fluzone High Dose (0.7ml) (Dialysis) 90662
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
6219916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.47 |
| Max. Negotiated Rate |
$408.35 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Aetna Managed Medicare |
$17.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.00
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.80
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: NAPHCARE Commercial |
$37.44
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$40.56
|
| Rate for Payer: Quartz Medicare Advantage |
$37.44
|
| Rate for Payer: The Alliance Commercial |
$408.35
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$190.85
|
|
