|
Fluzone High Dose (0.7ml) (Dialysis) 90662
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
6219916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
Fluzone High Dose (0.7ml) - Flu Virus, Inactivated Charge
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
5609706
|
|
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
|
|
|
Fluzone High Dose (0.7ml) - Flu Virus, Inactivated Charge
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
5609706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
Fluzone High Dose (0.7ml) - Flu Virus, Inactivated Charge
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
5609706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.46 |
| Max. Negotiated Rate |
$255.22 |
| Rate for Payer: Aetna Commercial |
$59.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| 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 |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$59.28
|
| 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 |
$56.78
|
| Rate for Payer: HFN Commercial |
$59.28
|
| 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 |
$49.92
|
| Rate for Payer: NAPHCARE Commercial |
$153.13
|
| Rate for Payer: Preferred Network Access Commercial |
$59.28
|
| Rate for Payer: Quartz Beloit One Network |
$27.46
|
| Rate for Payer: Quartz Commercial |
$35.57
|
| 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 |
$34.32
|
| Rate for Payer: WPS Commercial |
$190.85
|
|
|
Fluzone High Dose (0.7ml) (Peritoneal) 90662
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
6219917
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
Fluzone High Dose (0.7ml) (Peritoneal) 90662
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
6219917
|
|
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
|
|
|
Fluzone high Dose 90662
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3811014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.20 |
| Max. Negotiated Rate |
$255.22 |
| Rate for Payer: Aetna Commercial |
$65.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| 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 |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$65.21
|
| 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 |
$62.46
|
| Rate for Payer: HFN Commercial |
$65.21
|
| 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 |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$153.13
|
| Rate for Payer: Preferred Network Access Commercial |
$65.21
|
| Rate for Payer: Quartz Beloit One Network |
$30.20
|
| Rate for Payer: Quartz Commercial |
$39.12
|
| 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 |
$37.75
|
| Rate for Payer: WPS Commercial |
$190.85
|
|
|
Fluzone high Dose 90662
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3811014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.22 |
| Max. Negotiated Rate |
$408.35 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$19.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.00
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.48
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$41.18
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$44.62
|
| Rate for Payer: Quartz Medicare Advantage |
$41.18
|
| Rate for Payer: The Alliance Commercial |
$408.35
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$190.85
|
|
|
Fluzone high Dose 90662
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3811014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.63 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$41.18
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
Fluzone High Dose 90662 Medicare
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3811015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.34 |
| Max. Negotiated Rate |
$255.22 |
| Rate for Payer: Aetna Commercial |
$50.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| 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 |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$50.39
|
| 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 |
$48.27
|
| Rate for Payer: HFN Commercial |
$50.39
|
| 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 |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$153.13
|
| Rate for Payer: Preferred Network Access Commercial |
$50.39
|
| Rate for Payer: Quartz Beloit One Network |
$23.34
|
| Rate for Payer: Quartz Commercial |
$30.23
|
| 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 |
$29.17
|
| Rate for Payer: WPS Commercial |
$190.85
|
|
|
Fluzone High Dose 90662 Medicare
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3811015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$31.82
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
Fluzone High Dose 90662 Medicare
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3811015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$408.35 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$14.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.00
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.78
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$31.82
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$34.48
|
| Rate for Payer: Quartz Medicare Advantage |
$31.82
|
| Rate for Payer: The Alliance Commercial |
$408.35
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$190.85
|
|
|
Fluzone High Dose 90672
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
CPT 90672
|
| Hospital Charge Code |
3795877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.14 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$41.81
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
Fluzone High Dose 90672
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
CPT 90672
|
| Hospital Charge Code |
3795877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$72.25 |
| Rate for Payer: Aetna Commercial |
$66.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$66.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.90
|
| Rate for Payer: Health EOS Commercial |
$63.41
|
| Rate for Payer: HFN Commercial |
$66.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.81
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$66.20
|
| Rate for Payer: Quartz Beloit One Network |
$30.66
|
| Rate for Payer: Quartz Commercial |
$39.72
|
| Rate for Payer: The Alliance Commercial |
$34.84
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$72.25
|
|
|
Fluzone High Dose 90672
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
CPT 90672
|
| Hospital Charge Code |
3795877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.51 |
| Max. Negotiated Rate |
$72.25 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$19.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.23
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.26
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$41.81
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$45.29
|
| Rate for Payer: Quartz Medicare Advantage |
$41.81
|
| Rate for Payer: The Alliance Commercial |
$24.39
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$72.25
|
|
|
Fluzone High Dose 90672 Medicare
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 90672
|
| Hospital Charge Code |
3795878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$31.82
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
Fluzone High Dose 90672 Medicare
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
CPT 90672
|
| Hospital Charge Code |
3795878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.34 |
| Max. Negotiated Rate |
$72.25 |
| Rate for Payer: Aetna Commercial |
$50.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$50.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.90
|
| Rate for Payer: Health EOS Commercial |
$48.27
|
| Rate for Payer: HFN Commercial |
$50.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.81
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$50.39
|
| Rate for Payer: Quartz Beloit One Network |
$23.34
|
| Rate for Payer: Quartz Commercial |
$30.23
|
| Rate for Payer: The Alliance Commercial |
$26.52
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$72.25
|
|
|
Fluzone High Dose 90672 Medicare
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 90672
|
| Hospital Charge Code |
3795878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$72.25 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$14.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.23
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.78
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$31.82
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$34.48
|
| Rate for Payer: Quartz Medicare Advantage |
$31.82
|
| Rate for Payer: The Alliance Commercial |
$18.56
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$72.25
|
|
|
Fluzone MVD (0.5ml) 6mo & up - Flu Virus, Inactivated Charge
|
Professional
|
Both
|
$24.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
5609707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$23.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$23.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.71
|
| Rate for Payer: Health EOS Commercial |
$22.71
|
| Rate for Payer: HFN Commercial |
$23.71
|
| 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 |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$23.71
|
| Rate for Payer: Quartz Beloit One Network |
$10.98
|
| Rate for Payer: Quartz Commercial |
$14.23
|
| Rate for Payer: The Alliance Commercial |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$54.28
|
|
|
Fluzone MVD (0.5ml) 6mo & up - Flu Virus, Inactivated Charge
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
5609707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Aetna Managed Medicare |
$6.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.73
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.72
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: NAPHCARE Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$16.22
|
| Rate for Payer: Quartz Medicare Advantage |
$14.98
|
| Rate for Payer: The Alliance Commercial |
$8.74
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$54.28
|
|
|
Fluzone MVD (0.5ml) 6mo & up - Flu Virus, Inactivated Charge
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
5609707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$14.98
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$18.49
|
|
|
Fluzone MVD Low Dose (0.5ml) 6mo & up (Dialysis) 90688
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
6219918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$14.98
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$18.49
|
|
|
Fluzone MVD Low Dose (0.5ml) 6mo & up (Dialysis) 90688
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
6219918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Aetna Managed Medicare |
$6.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.73
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.72
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: NAPHCARE Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$16.22
|
| Rate for Payer: Quartz Medicare Advantage |
$14.98
|
| Rate for Payer: The Alliance Commercial |
$8.74
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$54.28
|
|
|
Fluzone MVD Low Dose (0.5ml) 6mo & up (Peritoneal) 90688
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
6219919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Aetna Managed Medicare |
$6.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.73
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.72
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: NAPHCARE Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$16.22
|
| Rate for Payer: Quartz Medicare Advantage |
$14.98
|
| Rate for Payer: The Alliance Commercial |
$8.74
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$54.28
|
|
|
Fluzone MVD Low Dose (0.5ml) 6mo & up (Peritoneal) 90688
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
6219919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$14.98
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$18.49
|
|
