|
Phototherapy Double - Daily Charges
|
Facility
|
OP
|
$602.00
|
|
| Hospital Charge Code |
3003959
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$168.56 |
| Max. Negotiated Rate |
$2,408.00 |
| Rate for Payer: Aetna Commercial |
$541.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.72
|
| Rate for Payer: Aetna Managed Medicare |
$168.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$391.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$301.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.06
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$553.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.88
|
| Rate for Payer: Health EOS Commercial |
$535.78
|
| Rate for Payer: HFN Commercial |
$553.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$451.50
|
| Rate for Payer: Multiplan Commercial |
$481.60
|
| Rate for Payer: NAPHCARE Commercial |
$361.20
|
| Rate for Payer: Preferred Network Access Commercial |
$553.84
|
| Rate for Payer: Quartz Beloit One Network |
$294.98
|
| Rate for Payer: Quartz Commercial |
$391.30
|
| Rate for Payer: Quartz Medicare Advantage |
$361.20
|
| Rate for Payer: The Alliance Commercial |
$2,408.00
|
| Rate for Payer: WEA Trust Commercial |
$331.10
|
| Rate for Payer: WPS Commercial |
$445.90
|
|
|
Phototherapy Double - Daily Charges
|
Facility
|
IP
|
$602.00
|
|
| Hospital Charge Code |
3003959
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$294.98 |
| Max. Negotiated Rate |
$553.84 |
| Rate for Payer: Aetna Commercial |
$541.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.06
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$553.84
|
| Rate for Payer: Health EOS Commercial |
$535.78
|
| Rate for Payer: HFN Commercial |
$553.84
|
| Rate for Payer: Multiplan Commercial |
$481.60
|
| Rate for Payer: NAPHCARE Commercial |
$361.20
|
| Rate for Payer: Preferred Network Access Commercial |
$553.84
|
| Rate for Payer: Quartz Beloit One Network |
$294.98
|
| Rate for Payer: Quartz Commercial |
$361.20
|
| Rate for Payer: WEA Trust Commercial |
$331.10
|
| Rate for Payer: WPS Commercial |
$445.90
|
|
|
Phototherapy Double - Nursery Daily Charges
|
Facility
|
OP
|
$602.00
|
|
| Hospital Charge Code |
3003951
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$168.56 |
| Max. Negotiated Rate |
$2,408.00 |
| Rate for Payer: Aetna Commercial |
$541.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.72
|
| Rate for Payer: Aetna Managed Medicare |
$168.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$391.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$301.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.06
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$553.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.88
|
| Rate for Payer: Health EOS Commercial |
$535.78
|
| Rate for Payer: HFN Commercial |
$553.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$451.50
|
| Rate for Payer: Multiplan Commercial |
$481.60
|
| Rate for Payer: NAPHCARE Commercial |
$361.20
|
| Rate for Payer: Preferred Network Access Commercial |
$553.84
|
| Rate for Payer: Quartz Beloit One Network |
$294.98
|
| Rate for Payer: Quartz Commercial |
$391.30
|
| Rate for Payer: Quartz Medicare Advantage |
$361.20
|
| Rate for Payer: The Alliance Commercial |
$2,408.00
|
| Rate for Payer: WEA Trust Commercial |
$331.10
|
| Rate for Payer: WPS Commercial |
$445.90
|
|
|
Phototherapy Double - Nursery Daily Charges
|
Facility
|
IP
|
$602.00
|
|
| Hospital Charge Code |
3003951
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$294.98 |
| Max. Negotiated Rate |
$553.84 |
| Rate for Payer: Aetna Commercial |
$541.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.06
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$553.84
|
| Rate for Payer: Health EOS Commercial |
$535.78
|
| Rate for Payer: HFN Commercial |
$553.84
|
| Rate for Payer: Multiplan Commercial |
$481.60
|
| Rate for Payer: NAPHCARE Commercial |
$361.20
|
| Rate for Payer: Preferred Network Access Commercial |
$553.84
|
| Rate for Payer: Quartz Beloit One Network |
$294.98
|
| Rate for Payer: Quartz Commercial |
$361.20
|
| Rate for Payer: WEA Trust Commercial |
$331.10
|
| Rate for Payer: WPS Commercial |
$445.90
|
|
|
Phototherapy Single - Daily Charges
|
Facility
|
IP
|
$259.00
|
|
| Hospital Charge Code |
3003958
|
|
Hospital Revenue Code
|
121
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$238.28 |
| Rate for Payer: Aetna Commercial |
$233.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$137.27
|
| Rate for Payer: Cash Price |
$77.70
|
| Rate for Payer: Cigna Commercial |
$238.28
|
| Rate for Payer: Health EOS Commercial |
$230.51
|
| Rate for Payer: HFN Commercial |
$238.28
|
| Rate for Payer: Multiplan Commercial |
$207.20
|
| Rate for Payer: NAPHCARE Commercial |
$155.40
|
| Rate for Payer: Preferred Network Access Commercial |
$238.28
|
| Rate for Payer: Quartz Beloit One Network |
$126.91
|
| Rate for Payer: Quartz Commercial |
$155.40
|
| Rate for Payer: WEA Trust Commercial |
$142.45
|
| Rate for Payer: WPS Commercial |
$191.84
|
|
|
Phototherapy Single - Nursery Daily Charges
|
Facility
|
IP
|
$275.00
|
|
| Hospital Charge Code |
3003950
|
|
Hospital Revenue Code
|
231
|
| Min. Negotiated Rate |
$134.75 |
| Max. Negotiated Rate |
$253.00 |
| Rate for Payer: Aetna Commercial |
$247.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.75
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$253.00
|
| Rate for Payer: Health EOS Commercial |
$244.75
|
| Rate for Payer: HFN Commercial |
$253.00
|
| Rate for Payer: Multiplan Commercial |
$220.00
|
| Rate for Payer: NAPHCARE Commercial |
$165.00
|
| Rate for Payer: Preferred Network Access Commercial |
$253.00
|
| Rate for Payer: Quartz Beloit One Network |
$134.75
|
| Rate for Payer: Quartz Commercial |
$165.00
|
| Rate for Payer: WEA Trust Commercial |
$151.25
|
| Rate for Payer: WPS Commercial |
$203.69
|
|
|
Phototherapy Single - Nursery Daily Charges
|
Facility
|
OP
|
$275.00
|
|
| Hospital Charge Code |
3003950
|
|
Hospital Revenue Code
|
231
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Aetna Commercial |
$247.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.50
|
| Rate for Payer: Aetna Managed Medicare |
$77.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$178.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.75
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$253.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.89
|
| Rate for Payer: Health EOS Commercial |
$244.75
|
| Rate for Payer: HFN Commercial |
$253.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$206.25
|
| Rate for Payer: Multiplan Commercial |
$220.00
|
| Rate for Payer: NAPHCARE Commercial |
$165.00
|
| Rate for Payer: Preferred Network Access Commercial |
$253.00
|
| Rate for Payer: Quartz Beloit One Network |
$134.75
|
| Rate for Payer: Quartz Commercial |
$178.75
|
| Rate for Payer: Quartz Medicare Advantage |
$165.00
|
| Rate for Payer: The Alliance Commercial |
$1,100.00
|
| Rate for Payer: WEA Trust Commercial |
$151.25
|
| Rate for Payer: WPS Commercial |
$203.69
|
|
|
Phototherapy Triple - Daily Charges
|
Facility
|
IP
|
$904.00
|
|
| Hospital Charge Code |
3003957
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$442.96 |
| Max. Negotiated Rate |
$831.68 |
| Rate for Payer: Aetna Commercial |
$813.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$777.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$479.12
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$831.68
|
| Rate for Payer: Health EOS Commercial |
$804.56
|
| Rate for Payer: HFN Commercial |
$831.68
|
| Rate for Payer: Multiplan Commercial |
$723.20
|
| Rate for Payer: NAPHCARE Commercial |
$542.40
|
| Rate for Payer: Preferred Network Access Commercial |
$831.68
|
| Rate for Payer: Quartz Beloit One Network |
$442.96
|
| Rate for Payer: Quartz Commercial |
$542.40
|
| Rate for Payer: WEA Trust Commercial |
$497.20
|
| Rate for Payer: WPS Commercial |
$669.59
|
|
|
Phototherapy Triple - Daily Charges
|
Facility
|
OP
|
$904.00
|
|
| Hospital Charge Code |
3003957
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$253.12 |
| Max. Negotiated Rate |
$3,616.00 |
| Rate for Payer: Aetna Commercial |
$813.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$777.44
|
| Rate for Payer: Aetna Managed Medicare |
$253.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$587.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$452.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$433.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$479.12
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$831.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$505.88
|
| Rate for Payer: Health EOS Commercial |
$804.56
|
| Rate for Payer: HFN Commercial |
$831.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$678.00
|
| Rate for Payer: Multiplan Commercial |
$723.20
|
| Rate for Payer: NAPHCARE Commercial |
$542.40
|
| Rate for Payer: Preferred Network Access Commercial |
$831.68
|
| Rate for Payer: Quartz Beloit One Network |
$442.96
|
| Rate for Payer: Quartz Commercial |
$587.60
|
| Rate for Payer: Quartz Medicare Advantage |
$542.40
|
| Rate for Payer: The Alliance Commercial |
$3,616.00
|
| Rate for Payer: WEA Trust Commercial |
$497.20
|
| Rate for Payer: WPS Commercial |
$669.59
|
|
|
Phototherapy Triple - Nursery Daily Charges
|
Facility
|
OP
|
$904.00
|
|
| Hospital Charge Code |
3003949
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$253.12 |
| Max. Negotiated Rate |
$3,616.00 |
| Rate for Payer: Aetna Commercial |
$813.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$777.44
|
| Rate for Payer: Aetna Managed Medicare |
$253.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$587.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$452.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$433.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$479.12
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$831.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$505.88
|
| Rate for Payer: Health EOS Commercial |
$804.56
|
| Rate for Payer: HFN Commercial |
$831.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$678.00
|
| Rate for Payer: Multiplan Commercial |
$723.20
|
| Rate for Payer: NAPHCARE Commercial |
$542.40
|
| Rate for Payer: Preferred Network Access Commercial |
$831.68
|
| Rate for Payer: Quartz Beloit One Network |
$442.96
|
| Rate for Payer: Quartz Commercial |
$587.60
|
| Rate for Payer: Quartz Medicare Advantage |
$542.40
|
| Rate for Payer: The Alliance Commercial |
$3,616.00
|
| Rate for Payer: WEA Trust Commercial |
$497.20
|
| Rate for Payer: WPS Commercial |
$669.59
|
|
|
Phototherapy Triple - Nursery Daily Charges
|
Facility
|
IP
|
$904.00
|
|
| Hospital Charge Code |
3003949
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$442.96 |
| Max. Negotiated Rate |
$831.68 |
| Rate for Payer: Aetna Commercial |
$813.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$777.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$479.12
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$831.68
|
| Rate for Payer: Health EOS Commercial |
$804.56
|
| Rate for Payer: HFN Commercial |
$831.68
|
| Rate for Payer: Multiplan Commercial |
$723.20
|
| Rate for Payer: NAPHCARE Commercial |
$542.40
|
| Rate for Payer: Preferred Network Access Commercial |
$831.68
|
| Rate for Payer: Quartz Beloit One Network |
$442.96
|
| Rate for Payer: Quartz Commercial |
$542.40
|
| Rate for Payer: WEA Trust Commercial |
$497.20
|
| Rate for Payer: WPS Commercial |
$669.59
|
|
|
PHOTOVAPORIZATION PROSTATE/BLADDER
|
Facility
|
IP
|
$12,167.00
|
|
|
Service Code
|
CPT 52648
|
| Hospital Charge Code |
2960194
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,961.83 |
| Max. Negotiated Rate |
$11,193.64 |
| Rate for Payer: Aetna Commercial |
$10,950.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,463.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,448.51
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cigna Commercial |
$11,193.64
|
| Rate for Payer: Health EOS Commercial |
$10,828.63
|
| Rate for Payer: HFN Commercial |
$11,193.64
|
| Rate for Payer: Multiplan Commercial |
$9,733.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,300.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,193.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,961.83
|
| Rate for Payer: Quartz Commercial |
$7,300.20
|
| Rate for Payer: WEA Trust Commercial |
$6,691.85
|
| Rate for Payer: WPS Commercial |
$9,012.10
|
|
|
PHOTOVAPORIZATION PROSTATE/BLADDER
|
Facility
|
OP
|
$12,167.00
|
|
|
Service Code
|
CPT 52648
|
| Hospital Charge Code |
2960194
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$20,457.48 |
| Rate for Payer: Aetna Commercial |
$10,950.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,463.62
|
| Rate for Payer: Aetna Managed Medicare |
$5,114.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$5,114.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,448.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,114.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,114.37
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cigna Commercial |
$11,193.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,114.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,114.37
|
| Rate for Payer: Health EOS Commercial |
$10,828.63
|
| Rate for Payer: HFN Commercial |
$11,193.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,025.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,114.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,114.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,114.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,114.37
|
| Rate for Payer: Multiplan Commercial |
$9,733.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,671.56
|
| Rate for Payer: Preferred Network Access Commercial |
$11,193.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,961.83
|
| Rate for Payer: Quartz Commercial |
$7,908.55
|
| Rate for Payer: Quartz Medicare Advantage |
$5,114.37
|
| Rate for Payer: The Alliance Commercial |
$20,457.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,114.37
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: WEA Trust Commercial |
$6,691.85
|
| Rate for Payer: Wellcare Medicare |
$5,114.37
|
| Rate for Payer: WPS Commercial |
$9,012.10
|
|
|
pH, Pleural Fluid
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$53.36 |
| Rate for Payer: Aetna Commercial |
$52.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Aetna Managed Medicare |
$3.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.94
|
| Rate for Payer: Anthem Medicaid |
$3.70
|
| Rate for Payer: Anthem Medicare Advantage |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.58
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$53.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.46
|
| Rate for Payer: Dean Health Medicaid |
$3.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.58
|
| Rate for Payer: Health EOS Commercial |
$51.62
|
| Rate for Payer: HFN Commercial |
$53.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.58
|
| Rate for Payer: Managed Health Services Medicaid |
$3.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: NAPHCARE Commercial |
$5.37
|
| Rate for Payer: Preferred Network Access Commercial |
$53.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.70
|
| Rate for Payer: Quartz Beloit One Network |
$28.42
|
| Rate for Payer: Quartz Commercial |
$37.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3.58
|
| Rate for Payer: The Alliance Commercial |
$14.32
|
| Rate for Payer: United Healthcare Medicaid |
$3.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.58
|
| Rate for Payer: United Healthcare PPO |
$43.50
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: Wellcare Medicare |
$3.58
|
| Rate for Payer: WMAP Medicaid |
$3.70
|
| Rate for Payer: WPS Commercial |
$42.96
|
|
|
pH, Pleural Fluid
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.42 |
| Max. Negotiated Rate |
$53.36 |
| Rate for Payer: Aetna Commercial |
$52.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.74
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$53.36
|
| Rate for Payer: Health EOS Commercial |
$51.62
|
| Rate for Payer: HFN Commercial |
$53.36
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: NAPHCARE Commercial |
$34.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.36
|
| Rate for Payer: Quartz Beloit One Network |
$28.42
|
| Rate for Payer: Quartz Commercial |
$34.80
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$42.96
|
|
|
pH, Pleural Fluid
|
Professional
|
Both
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.80
|
| Rate for Payer: Health EOS Commercial |
$52.78
|
| Rate for Payer: HFN Commercial |
$55.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.64
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: Preferred Network Access Commercial |
$55.10
|
| Rate for Payer: Quartz Beloit One Network |
$25.52
|
| Rate for Payer: Quartz Commercial |
$33.06
|
| Rate for Payer: The Alliance Commercial |
$29.00
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$42.96
|
|
|
pH, Urine
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: HFN Commercial |
$20.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.64
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
pH, Urine
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$3.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.94
|
| Rate for Payer: Anthem Medicaid |
$3.70
|
| Rate for Payer: Anthem Medicare Advantage |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.58
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Dean Health Medicaid |
$3.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.58
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.58
|
| Rate for Payer: Managed Health Services Medicaid |
$3.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$5.37
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.70
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3.58
|
| Rate for Payer: The Alliance Commercial |
$14.32
|
| Rate for Payer: United Healthcare Medicaid |
$3.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.58
|
| Rate for Payer: United Healthcare PPO |
$16.50
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: Wellcare Medicare |
$3.58
|
| Rate for Payer: WMAP Medicaid |
$3.70
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
pH, Urine
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
pH, Venous
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$676.20 |
| Rate for Payer: Aetna Commercial |
$661.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$632.10
|
| Rate for Payer: Aetna Managed Medicare |
$11.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.26
|
| Rate for Payer: Anthem Medicaid |
$11.37
|
| Rate for Payer: Anthem Medicare Advantage |
$11.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$389.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.00
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$676.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$411.31
|
| Rate for Payer: Dean Health Medicaid |
$11.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.00
|
| Rate for Payer: Health EOS Commercial |
$654.15
|
| Rate for Payer: HFN Commercial |
$676.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.00
|
| Rate for Payer: Managed Health Services Medicaid |
$11.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.00
|
| Rate for Payer: Multiplan Commercial |
$588.00
|
| Rate for Payer: NAPHCARE Commercial |
$16.50
|
| Rate for Payer: Preferred Network Access Commercial |
$676.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.37
|
| Rate for Payer: Quartz Beloit One Network |
$360.15
|
| Rate for Payer: Quartz Commercial |
$477.75
|
| Rate for Payer: Quartz Medicare Advantage |
$11.00
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: United Healthcare Medicaid |
$11.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.00
|
| Rate for Payer: United Healthcare PPO |
$551.25
|
| Rate for Payer: WEA Trust Commercial |
$404.25
|
| Rate for Payer: Wellcare Medicare |
$11.00
|
| Rate for Payer: WMAP Medicaid |
$11.37
|
| Rate for Payer: WPS Commercial |
$544.41
|
|
|
pH, Venous
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$360.15 |
| Max. Negotiated Rate |
$676.20 |
| Rate for Payer: Aetna Commercial |
$661.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$632.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$389.55
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$676.20
|
| Rate for Payer: Health EOS Commercial |
$654.15
|
| Rate for Payer: HFN Commercial |
$676.20
|
| Rate for Payer: Multiplan Commercial |
$588.00
|
| Rate for Payer: NAPHCARE Commercial |
$441.00
|
| Rate for Payer: Preferred Network Access Commercial |
$676.20
|
| Rate for Payer: Quartz Beloit One Network |
$360.15
|
| Rate for Payer: Quartz Commercial |
$441.00
|
| Rate for Payer: WEA Trust Commercial |
$404.25
|
| Rate for Payer: WPS Commercial |
$544.41
|
|
|
pH, Venous
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.83 |
| Max. Negotiated Rate |
$698.25 |
| Rate for Payer: Aetna Commercial |
$698.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$632.10
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$698.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$367.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$441.00
|
| Rate for Payer: Health EOS Commercial |
$668.85
|
| Rate for Payer: HFN Commercial |
$698.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38.83
|
| Rate for Payer: Multiplan Commercial |
$588.00
|
| Rate for Payer: Preferred Network Access Commercial |
$698.25
|
| Rate for Payer: Quartz Beloit One Network |
$323.40
|
| Rate for Payer: Quartz Commercial |
$418.95
|
| Rate for Payer: The Alliance Commercial |
$367.50
|
| Rate for Payer: WEA Trust Commercial |
$404.25
|
| Rate for Payer: WPS Commercial |
$544.41
|
|
|
Physical Performance Test Charges
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
CPT 97750 GP
|
| Hospital Charge Code |
2472554
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$1,284.00 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$192.60
|
| Rate for Payer: The Alliance Commercial |
$1,284.00
|
| Rate for Payer: United Healthcare PPO |
$240.75
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Physical Performance Test Charges
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
CPT 97750 GP
|
| Hospital Charge Code |
2472554
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$192.60
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Physical Perf Test - FCA Charges
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
3007746
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$68.11 |
| Max. Negotiated Rate |
$127.88 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$83.40
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$83.40
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
