|
Physical Perf Test - FCA Charges
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
3007746
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$38.92 |
| Max. Negotiated Rate |
$556.00 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Aetna Managed Medicare |
$38.92
|
| 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 |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.78
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| 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 |
$90.35
|
| Rate for Payer: Quartz Medicare Advantage |
$83.40
|
| Rate for Payer: The Alliance Commercial |
$556.00
|
| Rate for Payer: United Healthcare PPO |
$104.25
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
Physical Perf Test - Missed FCA Charges
|
Facility
|
IP
|
$587.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
3007750
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$287.63 |
| Max. Negotiated Rate |
$540.04 |
| Rate for Payer: Aetna Commercial |
$528.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$504.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.11
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$540.04
|
| Rate for Payer: Health EOS Commercial |
$522.43
|
| Rate for Payer: HFN Commercial |
$540.04
|
| Rate for Payer: Multiplan Commercial |
$469.60
|
| Rate for Payer: NAPHCARE Commercial |
$352.20
|
| Rate for Payer: Preferred Network Access Commercial |
$540.04
|
| Rate for Payer: Quartz Beloit One Network |
$287.63
|
| Rate for Payer: Quartz Commercial |
$352.20
|
| Rate for Payer: WEA Trust Commercial |
$322.85
|
| Rate for Payer: WPS Commercial |
$434.79
|
|
|
Physical Perf Test - Missed FCA Charges
|
Facility
|
OP
|
$587.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
3007750
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$164.36 |
| Max. Negotiated Rate |
$2,348.00 |
| Rate for Payer: Aetna Commercial |
$528.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$504.82
|
| Rate for Payer: Aetna Managed Medicare |
$164.36
|
| 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 |
$311.11
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$540.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$328.49
|
| Rate for Payer: Health EOS Commercial |
$522.43
|
| Rate for Payer: HFN Commercial |
$540.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$469.60
|
| Rate for Payer: NAPHCARE Commercial |
$352.20
|
| Rate for Payer: Preferred Network Access Commercial |
$540.04
|
| Rate for Payer: Quartz Beloit One Network |
$287.63
|
| Rate for Payer: Quartz Commercial |
$381.55
|
| Rate for Payer: Quartz Medicare Advantage |
$352.20
|
| Rate for Payer: The Alliance Commercial |
$2,348.00
|
| Rate for Payer: United Healthcare PPO |
$440.25
|
| Rate for Payer: WEA Trust Commercial |
$322.85
|
| Rate for Payer: WPS Commercial |
$434.79
|
|
|
Physical Perf Test - Modified FCA Charges
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
3007748
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.64 |
| Max. Negotiated Rate |
$652.00 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Aetna Managed Medicare |
$45.64
|
| 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 |
$86.39
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.21
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$97.80
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$105.95
|
| Rate for Payer: Quartz Medicare Advantage |
$97.80
|
| Rate for Payer: The Alliance Commercial |
$652.00
|
| Rate for Payer: United Healthcare PPO |
$122.25
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
Physical Perf Test - Modified FCA Charges
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
3007748
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$79.87 |
| Max. Negotiated Rate |
$149.96 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.39
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$97.80
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$97.80
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
Physical Perf Test WH Eval Charges
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
2564919
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$96.53 |
| Max. Negotiated Rate |
$181.24 |
| Rate for Payer: Aetna Commercial |
$177.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.41
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$181.24
|
| Rate for Payer: Health EOS Commercial |
$175.33
|
| Rate for Payer: HFN Commercial |
$181.24
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: NAPHCARE Commercial |
$118.20
|
| Rate for Payer: Preferred Network Access Commercial |
$181.24
|
| Rate for Payer: Quartz Beloit One Network |
$96.53
|
| Rate for Payer: Quartz Commercial |
$118.20
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
Physical Perf Test WH Eval Charges
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
2564919
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$55.16 |
| Max. Negotiated Rate |
$788.00 |
| Rate for Payer: Aetna Commercial |
$177.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Aetna Managed Medicare |
$55.16
|
| 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 |
$104.41
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$181.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.24
|
| Rate for Payer: Health EOS Commercial |
$175.33
|
| Rate for Payer: HFN Commercial |
$181.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: NAPHCARE Commercial |
$118.20
|
| Rate for Payer: Preferred Network Access Commercial |
$181.24
|
| Rate for Payer: Quartz Beloit One Network |
$96.53
|
| Rate for Payer: Quartz Commercial |
$128.05
|
| Rate for Payer: Quartz Medicare Advantage |
$118.20
|
| Rate for Payer: The Alliance Commercial |
$788.00
|
| Rate for Payer: United Healthcare PPO |
$147.75
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
Physical Perf Test WH Eval Charges OT
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
5294653
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$48.44 |
| Max. Negotiated Rate |
$692.00 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Aetna Managed Medicare |
$48.44
|
| 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 |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.81
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$112.45
|
| Rate for Payer: Quartz Medicare Advantage |
$103.80
|
| Rate for Payer: The Alliance Commercial |
$692.00
|
| Rate for Payer: United Healthcare PPO |
$129.75
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
Physical Perf Test WH Eval Charges OT
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
5294653
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$84.77 |
| Max. Negotiated Rate |
$159.16 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$103.80
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
Physician Certification For MC Home Health Service
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
HCPCS G0180
|
| Hospital Charge Code |
2957678
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.36 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna Commercial |
$184.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$184.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$97.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$176.54
|
| Rate for Payer: HFN Commercial |
$184.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$178.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$178.34
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: Preferred Network Access Commercial |
$184.30
|
| Rate for Payer: Quartz Beloit One Network |
$85.36
|
| Rate for Payer: Quartz Commercial |
$110.58
|
| Rate for Payer: The Alliance Commercial |
$97.00
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
Physician Recertification For MC Home Health Services
|
Professional
|
Both
|
$72.00
|
|
|
Service Code
|
HCPCS G0179
|
| Hospital Charge Code |
2957677
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$138.09 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.20
|
| Rate for Payer: Health EOS Commercial |
$65.52
|
| Rate for Payer: HFN Commercial |
$68.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$138.09
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$68.40
|
| Rate for Payer: Quartz Beloit One Network |
$31.68
|
| Rate for Payer: Quartz Commercial |
$41.04
|
| Rate for Payer: The Alliance Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
PHYSIO RING II ANNULOPLASTY
|
Facility
|
OP
|
$24,772.00
|
|
| Hospital Charge Code |
2965105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,936.16 |
| Max. Negotiated Rate |
$99,088.00 |
| Rate for Payer: Aetna Commercial |
$22,294.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,303.92
|
| Rate for Payer: Aetna Managed Medicare |
$6,936.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,101.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,386.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,890.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,129.16
|
| Rate for Payer: Cash Price |
$7,431.60
|
| Rate for Payer: Cigna Commercial |
$22,790.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,862.41
|
| Rate for Payer: Health EOS Commercial |
$22,047.08
|
| Rate for Payer: HFN Commercial |
$22,790.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,579.00
|
| Rate for Payer: Multiplan Commercial |
$19,817.60
|
| Rate for Payer: NAPHCARE Commercial |
$14,863.20
|
| Rate for Payer: Preferred Network Access Commercial |
$22,790.24
|
| Rate for Payer: Quartz Beloit One Network |
$12,138.28
|
| Rate for Payer: Quartz Commercial |
$16,101.80
|
| Rate for Payer: Quartz Medicare Advantage |
$14,863.20
|
| Rate for Payer: The Alliance Commercial |
$99,088.00
|
| Rate for Payer: WEA Trust Commercial |
$13,624.60
|
| Rate for Payer: WPS Commercial |
$18,348.62
|
|
|
PHYSIO RING II ANNULOPLASTY
|
Facility
|
IP
|
$24,772.00
|
|
| Hospital Charge Code |
2965105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,138.28 |
| Max. Negotiated Rate |
$22,790.24 |
| Rate for Payer: Aetna Commercial |
$22,294.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,303.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,129.16
|
| Rate for Payer: Cash Price |
$7,431.60
|
| Rate for Payer: Cigna Commercial |
$22,790.24
|
| Rate for Payer: Health EOS Commercial |
$22,047.08
|
| Rate for Payer: HFN Commercial |
$22,790.24
|
| Rate for Payer: Multiplan Commercial |
$19,817.60
|
| Rate for Payer: NAPHCARE Commercial |
$14,863.20
|
| Rate for Payer: Preferred Network Access Commercial |
$22,790.24
|
| Rate for Payer: Quartz Beloit One Network |
$12,138.28
|
| Rate for Payer: Quartz Commercial |
$14,863.20
|
| Rate for Payer: WEA Trust Commercial |
$13,624.60
|
| Rate for Payer: WPS Commercial |
$18,348.62
|
|
|
Phytonadione JW Waste Charge per 1 mg
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS J3430 JW
|
| Hospital Charge Code |
5266686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Aetna Managed Medicare |
$10.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.71
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$23.40
|
| Rate for Payer: Quartz Medicare Advantage |
$21.60
|
| Rate for Payer: The Alliance Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$7.01
|
|
|
Phytonadione JW Waste Charge per 1 mg
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS J3430 JW
|
| Hospital Charge Code |
5266686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$32.76
|
| Rate for Payer: HFN Commercial |
$34.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.20
|
| Rate for Payer: Quartz Beloit One Network |
$15.84
|
| Rate for Payer: Quartz Commercial |
$20.52
|
| Rate for Payer: The Alliance Commercial |
$18.00
|
| Rate for Payer: United Healthcare Medicaid |
$2.90
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$7.01
|
|
|
Phytonadione JW Waste Charge per 1 mg
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS J3430 JW
|
| Hospital Charge Code |
5266686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$21.60
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
PICC - blood drawn - Central IV Activity:
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
CPT 36592
|
| Hospital Charge Code |
4558646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.24 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.18
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$138.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.24
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$195.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$189.57
|
| Rate for Payer: HFN Commercial |
$195.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$170.40
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$195.96
|
| Rate for Payer: Quartz Beloit One Network |
$104.37
|
| Rate for Payer: Quartz Commercial |
$138.45
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$159.75
|
| Rate for Payer: WEA Trust Commercial |
$117.15
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$157.77
|
|
|
PICC - blood drawn - Central IV Activity:
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
CPT 36592
|
| Hospital Charge Code |
4558646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.37 |
| Max. Negotiated Rate |
$195.96 |
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.89
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$195.96
|
| Rate for Payer: Health EOS Commercial |
$189.57
|
| Rate for Payer: HFN Commercial |
$195.96
|
| Rate for Payer: Multiplan Commercial |
$170.40
|
| Rate for Payer: NAPHCARE Commercial |
$127.80
|
| Rate for Payer: Preferred Network Access Commercial |
$195.96
|
| Rate for Payer: Quartz Beloit One Network |
$104.37
|
| Rate for Payer: Quartz Commercial |
$127.80
|
| Rate for Payer: WEA Trust Commercial |
$117.15
|
| Rate for Payer: WPS Commercial |
$157.77
|
|
|
PICC Foam Plus - Central IV Dressing:
|
Facility
|
IP
|
$146.00
|
|
| Hospital Charge Code |
3120170
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
PICC Foam Plus - Central IV Dressing:
|
Facility
|
OP
|
$146.00
|
|
| Hospital Charge Code |
3120170
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$584.00 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Aetna Managed Medicare |
$40.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.70
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.50
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$94.90
|
| Rate for Payer: Quartz Medicare Advantage |
$87.60
|
| Rate for Payer: The Alliance Commercial |
$584.00
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
PICC Line Placement - CATH LAB ONLY
|
Facility
|
OP
|
$2,606.00
|
|
|
Service Code
|
CPT 36569
|
| Hospital Charge Code |
4548725
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,276.94 |
| Max. Negotiated Rate |
$6,331.88 |
| Rate for Payer: Aetna Commercial |
$2,345.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,241.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,582.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,582.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,381.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,582.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,582.97
|
| Rate for Payer: Cash Price |
$781.80
|
| Rate for Payer: Cash Price |
$781.80
|
| Rate for Payer: Cash Price |
$781.80
|
| Rate for Payer: Cigna Commercial |
$2,397.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,582.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,582.97
|
| Rate for Payer: Health EOS Commercial |
$2,319.34
|
| Rate for Payer: HFN Commercial |
$2,397.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,888.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,582.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,582.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,582.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,582.97
|
| Rate for Payer: Multiplan Commercial |
$2,084.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,374.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,397.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,276.94
|
| Rate for Payer: Quartz Commercial |
$1,693.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,582.97
|
| Rate for Payer: The Alliance Commercial |
$6,331.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,582.97
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: WEA Trust Commercial |
$1,433.30
|
| Rate for Payer: Wellcare Medicare |
$1,582.97
|
| Rate for Payer: WPS Commercial |
$1,930.26
|
|
|
PICC Line Placement - CATH LAB ONLY
|
Facility
|
IP
|
$2,606.00
|
|
|
Service Code
|
CPT 36569
|
| Hospital Charge Code |
4548725
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,276.94 |
| Max. Negotiated Rate |
$2,397.52 |
| Rate for Payer: Aetna Commercial |
$2,345.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,241.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,381.18
|
| Rate for Payer: Cash Price |
$781.80
|
| Rate for Payer: Cigna Commercial |
$2,397.52
|
| Rate for Payer: Health EOS Commercial |
$2,319.34
|
| Rate for Payer: HFN Commercial |
$2,397.52
|
| Rate for Payer: Multiplan Commercial |
$2,084.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,563.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,397.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,276.94
|
| Rate for Payer: Quartz Commercial |
$1,563.60
|
| Rate for Payer: WEA Trust Commercial |
$1,433.30
|
| Rate for Payer: WPS Commercial |
$1,930.26
|
|
|
Pigeon Serum
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
2942919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.41 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$65.40
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
Pigeon Serum
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
2942919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.29 |
| Max. Negotiated Rate |
$103.55 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.40
|
| Rate for Payer: Health EOS Commercial |
$99.19
|
| Rate for Payer: HFN Commercial |
$103.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.29
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: Preferred Network Access Commercial |
$103.55
|
| Rate for Payer: Quartz Beloit One Network |
$47.96
|
| Rate for Payer: Quartz Commercial |
$62.13
|
| Rate for Payer: The Alliance Commercial |
$54.50
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
Pigeon Serum
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
2942919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Aetna Managed Medicare |
$11.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.89
|
| Rate for Payer: Anthem Medicaid |
$12.38
|
| Rate for Payer: Anthem Medicare Advantage |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.98
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.00
|
| Rate for Payer: Dean Health Medicaid |
$12.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.98
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.98
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.98
|
| Rate for Payer: Managed Health Services Medicaid |
$12.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.98
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.97
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.38
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$70.85
|
| Rate for Payer: Quartz Medicare Advantage |
$11.98
|
| Rate for Payer: The Alliance Commercial |
$47.92
|
| Rate for Payer: United Healthcare Medicaid |
$12.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.98
|
| Rate for Payer: United Healthcare PPO |
$81.75
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: Wellcare Medicare |
$11.98
|
| Rate for Payer: WMAP Medicaid |
$12.38
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
