|
Mix PT 1 Hour
|
Professional
|
Both
|
$107.00
|
|
|
Service Code
|
CPT 85610
|
| Hospital Charge Code |
1050811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Aetna Commercial |
$101.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.02
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$101.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.20
|
| Rate for Payer: Health EOS Commercial |
$97.37
|
| Rate for Payer: HFN Commercial |
$101.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.14
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: Preferred Network Access Commercial |
$101.65
|
| Rate for Payer: Quartz Beloit One Network |
$47.08
|
| Rate for Payer: Quartz Commercial |
$60.99
|
| Rate for Payer: The Alliance Commercial |
$53.50
|
| Rate for Payer: WEA Trust Commercial |
$58.85
|
| Rate for Payer: WPS Commercial |
$79.25
|
|
|
Mix PT Immed
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT 85610
|
| Hospital Charge Code |
1050809
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$98.44 |
| Rate for Payer: Aetna Commercial |
$96.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.71
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$98.44
|
| Rate for Payer: Health EOS Commercial |
$95.23
|
| Rate for Payer: HFN Commercial |
$98.44
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: NAPHCARE Commercial |
$64.20
|
| Rate for Payer: Preferred Network Access Commercial |
$98.44
|
| Rate for Payer: Quartz Beloit One Network |
$52.43
|
| Rate for Payer: Quartz Commercial |
$64.20
|
| Rate for Payer: WEA Trust Commercial |
$58.85
|
| Rate for Payer: WPS Commercial |
$79.25
|
|
|
Mix PT Immed
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT 85610
|
| Hospital Charge Code |
1050809
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$98.44 |
| Rate for Payer: Aetna Commercial |
$96.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.02
|
| Rate for Payer: Aetna Managed Medicare |
$4.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7.51
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7.12
|
| Rate for Payer: Anthem Medicaid |
$4.43
|
| Rate for Payer: Anthem Medicare Advantage |
$4.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.29
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$98.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.88
|
| Rate for Payer: Dean Health Medicaid |
$4.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.29
|
| Rate for Payer: Health EOS Commercial |
$95.23
|
| Rate for Payer: HFN Commercial |
$98.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.29
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.29
|
| Rate for Payer: Managed Health Services Medicaid |
$4.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: NAPHCARE Commercial |
$6.44
|
| Rate for Payer: Preferred Network Access Commercial |
$98.44
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.43
|
| Rate for Payer: Quartz Beloit One Network |
$52.43
|
| Rate for Payer: Quartz Commercial |
$69.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.29
|
| Rate for Payer: The Alliance Commercial |
$17.16
|
| Rate for Payer: United Healthcare Medicaid |
$4.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.29
|
| Rate for Payer: United Healthcare PPO |
$80.25
|
| Rate for Payer: WEA Trust Commercial |
$58.85
|
| Rate for Payer: Wellcare Medicare |
$4.29
|
| Rate for Payer: WMAP Medicaid |
$4.43
|
| Rate for Payer: WPS Commercial |
$79.25
|
|
|
Mix PT Immed
|
Professional
|
Both
|
$107.00
|
|
|
Service Code
|
CPT 85610
|
| Hospital Charge Code |
1050809
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Aetna Commercial |
$101.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.02
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$101.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.20
|
| Rate for Payer: Health EOS Commercial |
$97.37
|
| Rate for Payer: HFN Commercial |
$101.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.14
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: Preferred Network Access Commercial |
$101.65
|
| Rate for Payer: Quartz Beloit One Network |
$47.08
|
| Rate for Payer: Quartz Commercial |
$60.99
|
| Rate for Payer: The Alliance Commercial |
$53.50
|
| Rate for Payer: WEA Trust Commercial |
$58.85
|
| Rate for Payer: WPS Commercial |
$79.25
|
|
|
Mix PTT 1 Hour
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
1050824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Aetna Commercial |
$144.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.72
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$144.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.20
|
| Rate for Payer: Health EOS Commercial |
$138.32
|
| Rate for Payer: HFN Commercial |
$144.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.22
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: Preferred Network Access Commercial |
$144.40
|
| Rate for Payer: Quartz Beloit One Network |
$66.88
|
| Rate for Payer: Quartz Commercial |
$86.64
|
| Rate for Payer: The Alliance Commercial |
$76.00
|
| Rate for Payer: WEA Trust Commercial |
$83.60
|
| Rate for Payer: WPS Commercial |
$112.59
|
|
|
Mix PTT 1 Hour
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
1050824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.48 |
| Max. Negotiated Rate |
$139.84 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.56
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$139.84
|
| Rate for Payer: Health EOS Commercial |
$135.28
|
| Rate for Payer: HFN Commercial |
$139.84
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: NAPHCARE Commercial |
$91.20
|
| Rate for Payer: Preferred Network Access Commercial |
$139.84
|
| Rate for Payer: Quartz Beloit One Network |
$74.48
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: WEA Trust Commercial |
$83.60
|
| Rate for Payer: WPS Commercial |
$112.59
|
|
|
Mix PTT 1 Hour
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
1050824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$139.84 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.72
|
| Rate for Payer: Aetna Managed Medicare |
$6.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.98
|
| Rate for Payer: Anthem Medicaid |
$6.21
|
| Rate for Payer: Anthem Medicare Advantage |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.01
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$139.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.06
|
| Rate for Payer: Dean Health Medicaid |
$6.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.01
|
| Rate for Payer: Health EOS Commercial |
$135.28
|
| Rate for Payer: HFN Commercial |
$139.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.01
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.01
|
| Rate for Payer: Managed Health Services Medicaid |
$6.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.01
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: NAPHCARE Commercial |
$9.02
|
| Rate for Payer: Preferred Network Access Commercial |
$139.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6.21
|
| Rate for Payer: Quartz Beloit One Network |
$74.48
|
| Rate for Payer: Quartz Commercial |
$98.80
|
| Rate for Payer: Quartz Medicare Advantage |
$6.01
|
| Rate for Payer: The Alliance Commercial |
$24.04
|
| Rate for Payer: United Healthcare Medicaid |
$6.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.01
|
| Rate for Payer: United Healthcare PPO |
$114.00
|
| Rate for Payer: WEA Trust Commercial |
$83.60
|
| Rate for Payer: Wellcare Medicare |
$6.01
|
| Rate for Payer: WMAP Medicaid |
$6.21
|
| Rate for Payer: WPS Commercial |
$112.59
|
|
|
Mix PTT Immed
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
1050822
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$139.84 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.72
|
| Rate for Payer: Aetna Managed Medicare |
$6.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.98
|
| Rate for Payer: Anthem Medicaid |
$6.21
|
| Rate for Payer: Anthem Medicare Advantage |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.01
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$139.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.06
|
| Rate for Payer: Dean Health Medicaid |
$6.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.01
|
| Rate for Payer: Health EOS Commercial |
$135.28
|
| Rate for Payer: HFN Commercial |
$139.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.01
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.01
|
| Rate for Payer: Managed Health Services Medicaid |
$6.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.01
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: NAPHCARE Commercial |
$9.02
|
| Rate for Payer: Preferred Network Access Commercial |
$139.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6.21
|
| Rate for Payer: Quartz Beloit One Network |
$74.48
|
| Rate for Payer: Quartz Commercial |
$98.80
|
| Rate for Payer: Quartz Medicare Advantage |
$6.01
|
| Rate for Payer: The Alliance Commercial |
$24.04
|
| Rate for Payer: United Healthcare Medicaid |
$6.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.01
|
| Rate for Payer: United Healthcare PPO |
$114.00
|
| Rate for Payer: WEA Trust Commercial |
$83.60
|
| Rate for Payer: Wellcare Medicare |
$6.01
|
| Rate for Payer: WMAP Medicaid |
$6.21
|
| Rate for Payer: WPS Commercial |
$112.59
|
|
|
Mix PTT Immed
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
1050822
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.48 |
| Max. Negotiated Rate |
$139.84 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.56
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$139.84
|
| Rate for Payer: Health EOS Commercial |
$135.28
|
| Rate for Payer: HFN Commercial |
$139.84
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: NAPHCARE Commercial |
$91.20
|
| Rate for Payer: Preferred Network Access Commercial |
$139.84
|
| Rate for Payer: Quartz Beloit One Network |
$74.48
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: WEA Trust Commercial |
$83.60
|
| Rate for Payer: WPS Commercial |
$112.59
|
|
|
Mix PTT Immed
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
1050822
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Aetna Commercial |
$144.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.72
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$144.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.20
|
| Rate for Payer: Health EOS Commercial |
$138.32
|
| Rate for Payer: HFN Commercial |
$144.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.22
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: Preferred Network Access Commercial |
$144.40
|
| Rate for Payer: Quartz Beloit One Network |
$66.88
|
| Rate for Payer: Quartz Commercial |
$86.64
|
| Rate for Payer: The Alliance Commercial |
$76.00
|
| Rate for Payer: WEA Trust Commercial |
$83.60
|
| Rate for Payer: WPS Commercial |
$112.59
|
|
|
MLC Device For IMRT Design and CBN
|
Facility
|
IP
|
$3,098.00
|
|
|
Service Code
|
CPT 77338
|
| Hospital Charge Code |
3040392
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,518.02 |
| Max. Negotiated Rate |
$2,850.16 |
| Rate for Payer: Aetna Commercial |
$2,788.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,664.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,641.94
|
| Rate for Payer: Cash Price |
$929.40
|
| Rate for Payer: Cigna Commercial |
$2,850.16
|
| Rate for Payer: Health EOS Commercial |
$2,757.22
|
| Rate for Payer: HFN Commercial |
$2,850.16
|
| Rate for Payer: Multiplan Commercial |
$2,478.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,858.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,850.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,518.02
|
| Rate for Payer: Quartz Commercial |
$1,858.80
|
| Rate for Payer: WEA Trust Commercial |
$1,703.90
|
| Rate for Payer: WPS Commercial |
$2,294.69
|
|
|
MLC Device For IMRT Design and CBN
|
Facility
|
OP
|
$3,098.00
|
|
|
Service Code
|
CPT 77338
|
| Hospital Charge Code |
3040392
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$365.21 |
| Max. Negotiated Rate |
$2,850.16 |
| Rate for Payer: Aetna Commercial |
$2,788.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,664.28
|
| Rate for Payer: Aetna Managed Medicare |
$365.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,369.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,095.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,040.85
|
| Rate for Payer: Anthem Medicare Advantage |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,641.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$365.21
|
| Rate for Payer: Cash Price |
$929.40
|
| Rate for Payer: Cash Price |
$929.40
|
| Rate for Payer: Cigna Commercial |
$2,850.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$365.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,733.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$365.21
|
| Rate for Payer: Health EOS Commercial |
$2,757.22
|
| Rate for Payer: HFN Commercial |
$2,850.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,358.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$365.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$365.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$365.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$365.21
|
| Rate for Payer: Multiplan Commercial |
$2,478.40
|
| Rate for Payer: NAPHCARE Commercial |
$547.82
|
| Rate for Payer: Preferred Network Access Commercial |
$2,850.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,518.02
|
| Rate for Payer: Quartz Commercial |
$2,013.70
|
| Rate for Payer: Quartz Medicare Advantage |
$365.21
|
| Rate for Payer: The Alliance Commercial |
$1,460.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$365.21
|
| Rate for Payer: United Healthcare PPO |
$2,323.50
|
| Rate for Payer: WEA Trust Commercial |
$1,703.90
|
| Rate for Payer: Wellcare Medicare |
$365.21
|
| Rate for Payer: WPS Commercial |
$2,294.69
|
|
|
MLH1
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 81292
|
| Hospital Charge Code |
5542923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$327.32 |
| Max. Negotiated Rate |
$614.56 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$400.80
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$400.80
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
MLH1
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 81292
|
| Hospital Charge Code |
5542923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$270.25 |
| Max. Negotiated Rate |
$2,701.60 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Aetna Managed Medicare |
$675.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,532.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,181.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,121.16
|
| Rate for Payer: Anthem Medicaid |
$270.25
|
| Rate for Payer: Anthem Medicare Advantage |
$675.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$675.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$675.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$675.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$270.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.81
|
| Rate for Payer: Dean Health Medicaid |
$270.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$675.40
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,512.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$675.40
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$270.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$675.40
|
| Rate for Payer: Managed Health Services Medicaid |
$281.06
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$675.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$675.40
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,013.10
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$270.25
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$434.20
|
| Rate for Payer: Quartz Medicare Advantage |
$675.40
|
| Rate for Payer: The Alliance Commercial |
$2,701.60
|
| Rate for Payer: United Healthcare Medicaid |
$270.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$675.40
|
| Rate for Payer: United Healthcare PPO |
$501.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: Wellcare Medicare |
$675.40
|
| Rate for Payer: WMAP Medicaid |
$270.25
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
MLH1
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
CPT 81292
|
| Hospital Charge Code |
5542923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$293.92 |
| Max. Negotiated Rate |
$2,384.16 |
| Rate for Payer: Aetna Commercial |
$634.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$634.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$334.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$400.80
|
| Rate for Payer: Health EOS Commercial |
$607.88
|
| Rate for Payer: HFN Commercial |
$634.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,384.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,384.16
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: Preferred Network Access Commercial |
$634.60
|
| Rate for Payer: Quartz Beloit One Network |
$293.92
|
| Rate for Payer: Quartz Commercial |
$380.76
|
| Rate for Payer: The Alliance Commercial |
$334.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
MLH1 Dup/Del
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 81294
|
| Hospital Charge Code |
5542924
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$327.32 |
| Max. Negotiated Rate |
$614.56 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$400.80
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$400.80
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
MLH1 Dup/Del
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
CPT 81294
|
| Hospital Charge Code |
5542924
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$293.92 |
| Max. Negotiated Rate |
$714.47 |
| Rate for Payer: Aetna Commercial |
$634.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$634.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$334.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$400.80
|
| Rate for Payer: Health EOS Commercial |
$607.88
|
| Rate for Payer: HFN Commercial |
$634.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$714.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$714.47
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: Preferred Network Access Commercial |
$634.60
|
| Rate for Payer: Quartz Beloit One Network |
$293.92
|
| Rate for Payer: Quartz Commercial |
$380.76
|
| Rate for Payer: The Alliance Commercial |
$334.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
MLH1 Dup/Del
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 81294
|
| Hospital Charge Code |
5542924
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.37 |
| Max. Negotiated Rate |
$809.60 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Aetna Managed Medicare |
$202.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$759.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$354.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$335.98
|
| Rate for Payer: Anthem Medicaid |
$121.37
|
| Rate for Payer: Anthem Medicare Advantage |
$202.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$202.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$202.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$202.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.81
|
| Rate for Payer: Dean Health Medicaid |
$121.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$202.40
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$752.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$202.40
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$121.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$202.40
|
| Rate for Payer: Managed Health Services Medicaid |
$126.22
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$202.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$202.40
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$303.60
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$121.37
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$434.20
|
| Rate for Payer: Quartz Medicare Advantage |
$202.40
|
| Rate for Payer: The Alliance Commercial |
$809.60
|
| Rate for Payer: United Healthcare Medicaid |
$121.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$202.40
|
| Rate for Payer: United Healthcare PPO |
$501.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: Wellcare Medicare |
$202.40
|
| Rate for Payer: WMAP Medicaid |
$121.37
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
MMR Vaccine, SC 90707
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3455572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.96 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Aetna Commercial |
$198.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$198.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.40
|
| Rate for Payer: Health EOS Commercial |
$190.19
|
| Rate for Payer: HFN Commercial |
$198.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.69
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: Preferred Network Access Commercial |
$198.55
|
| Rate for Payer: Quartz Beloit One Network |
$91.96
|
| Rate for Payer: Quartz Commercial |
$119.13
|
| Rate for Payer: The Alliance Commercial |
$104.50
|
| Rate for Payer: United Healthcare Medicaid |
$104.87
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
MMR Vaccine, SC 90707
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3455572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.41 |
| Max. Negotiated Rate |
$192.28 |
| Rate for Payer: Aetna Commercial |
$188.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.77
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$192.28
|
| Rate for Payer: Health EOS Commercial |
$186.01
|
| Rate for Payer: HFN Commercial |
$192.28
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: NAPHCARE Commercial |
$125.40
|
| Rate for Payer: Preferred Network Access Commercial |
$192.28
|
| Rate for Payer: Quartz Beloit One Network |
$102.41
|
| Rate for Payer: Quartz Commercial |
$125.40
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
MMR Vaccine, SC 90707
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
3455572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.52 |
| Max. Negotiated Rate |
$836.00 |
| Rate for Payer: Aetna Commercial |
$188.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Aetna Managed Medicare |
$58.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.77
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$192.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.96
|
| Rate for Payer: Health EOS Commercial |
$186.01
|
| Rate for Payer: HFN Commercial |
$192.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.75
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: NAPHCARE Commercial |
$125.40
|
| Rate for Payer: Preferred Network Access Commercial |
$192.28
|
| Rate for Payer: Quartz Beloit One Network |
$102.41
|
| Rate for Payer: Quartz Commercial |
$135.85
|
| Rate for Payer: Quartz Medicare Advantage |
$125.40
|
| Rate for Payer: The Alliance Commercial |
$836.00
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
MMR Vaccine, SC 90707VFC
|
Professional
|
Both
|
$80.83
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
5176606
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.57 |
| Max. Negotiated Rate |
$136.69 |
| Rate for Payer: Aetna Commercial |
$76.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.51
|
| Rate for Payer: Cash Price |
$24.25
|
| Rate for Payer: Cash Price |
$24.25
|
| Rate for Payer: Cigna Commercial |
$76.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.50
|
| Rate for Payer: Health EOS Commercial |
$73.56
|
| Rate for Payer: HFN Commercial |
$76.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.69
|
| Rate for Payer: Multiplan Commercial |
$64.66
|
| Rate for Payer: Preferred Network Access Commercial |
$76.79
|
| Rate for Payer: Quartz Beloit One Network |
$35.57
|
| Rate for Payer: Quartz Commercial |
$46.07
|
| Rate for Payer: The Alliance Commercial |
$40.42
|
| Rate for Payer: United Healthcare Medicaid |
$104.87
|
| Rate for Payer: WEA Trust Commercial |
$44.46
|
| Rate for Payer: WPS Commercial |
$59.87
|
|
|
MMR Vaccine, SC 90707VFC
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
5176606
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
MMR Vaccine, SC 90707VFC
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
5176606
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
MMRV Vaccine, SC 90710
|
Professional
|
Both
|
$394.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3455570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.36 |
| Max. Negotiated Rate |
$408.08 |
| Rate for Payer: Aetna Commercial |
$374.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.84
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$374.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.40
|
| Rate for Payer: Health EOS Commercial |
$358.54
|
| Rate for Payer: HFN Commercial |
$374.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$408.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$408.08
|
| Rate for Payer: Multiplan Commercial |
$315.20
|
| Rate for Payer: Preferred Network Access Commercial |
$374.30
|
| Rate for Payer: Quartz Beloit One Network |
$173.36
|
| Rate for Payer: Quartz Commercial |
$224.58
|
| Rate for Payer: The Alliance Commercial |
$197.00
|
| Rate for Payer: United Healthcare Medicaid |
$195.05
|
| Rate for Payer: WEA Trust Commercial |
$216.70
|
| Rate for Payer: WPS Commercial |
$291.84
|
|
