|
PGA Interp & Report
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
2778811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Aetna Managed Medicare |
$33.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.35
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.92
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: NAPHCARE Commercial |
$71.14
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$77.06
|
| Rate for Payer: Quartz Medicare Advantage |
$71.14
|
| Rate for Payer: The Alliance Commercial |
$59.28
|
| Rate for Payer: United Healthcare PPO |
$88.92
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
PGA Interp & Report
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
2778811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.09 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
PGA Iso/Extract Nuclerc Acid
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2778812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$49.30
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
PGA Iso/Extract Nuclerc Acid
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2778812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$23.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.98
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.62
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$49.30
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: Quartz Medicare Advantage |
$49.30
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: United Healthcare PPO |
$61.62
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
PGA Iso/Extract Nuclerc Acid
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2778812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna Commercial |
$78.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$78.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.30
|
| Rate for Payer: Health EOS Commercial |
$74.77
|
| Rate for Payer: HFN Commercial |
$78.05
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$78.05
|
| Rate for Payer: Quartz Beloit One Network |
$36.15
|
| Rate for Payer: Quartz Commercial |
$46.83
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
PGA Mutat ID Enz Ligation
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2778813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Mutat ID Enz Ligation
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2778813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$130.42 |
| Max. Negotiated Rate |
$281.58 |
| Rate for Payer: Aetna Commercial |
$281.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$281.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.84
|
| Rate for Payer: Health EOS Commercial |
$269.72
|
| Rate for Payer: HFN Commercial |
$281.58
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$281.58
|
| Rate for Payer: Quartz Beloit One Network |
$130.42
|
| Rate for Payer: Quartz Commercial |
$168.95
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Mutat ID Enz Ligation
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2778813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: United Healthcare PPO |
$222.30
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Sep & ID High Res
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2778814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: United Healthcare PPO |
$222.30
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Sep & ID High Res
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2778814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Sep & ID High Res
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2778814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$130.42 |
| Max. Negotiated Rate |
$281.58 |
| Rate for Payer: Aetna Commercial |
$281.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$281.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.84
|
| Rate for Payer: Health EOS Commercial |
$269.72
|
| Rate for Payer: HFN Commercial |
$281.58
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$281.58
|
| Rate for Payer: Quartz Beloit One Network |
$130.42
|
| Rate for Payer: Quartz Commercial |
$168.95
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PHALANGECTOMY, TOE, EACH TOE
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 28150
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
PHARMACOTHERAPY BY EXTENDED INFUSION
|
Facility
|
OP
|
$511.02
|
|
|
Service Code
|
EAPG 00110
|
| Min. Negotiated Rate |
$491.36 |
| Max. Negotiated Rate |
$511.02 |
| Rate for Payer: Anthem Medicaid |
$491.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$491.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$491.36
|
| Rate for Payer: Dean Health Medicaid |
$491.36
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$491.36
|
| Rate for Payer: Managed Health Services Medicaid |
$511.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$491.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$491.36
|
| Rate for Payer: United Healthcare Medicaid |
$491.36
|
|
|
PHARMACOTHERAPY EXCEPT BY EXTENDED INFUSION
|
Facility
|
OP
|
$191.30
|
|
|
Service Code
|
EAPG 00111
|
| Min. Negotiated Rate |
$183.95 |
| Max. Negotiated Rate |
$191.30 |
| Rate for Payer: Anthem Medicaid |
$183.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$183.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$183.95
|
| Rate for Payer: Dean Health Medicaid |
$183.95
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$183.95
|
| Rate for Payer: Managed Health Services Medicaid |
$191.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$183.95
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$183.95
|
| Rate for Payer: United Healthcare Medicaid |
$183.95
|
|
|
Phase 3 Cardiac Rehab
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
CPT 93797
|
| Hospital Charge Code |
3052594
|
|
Hospital Revenue Code
|
943
|
| Min. Negotiated Rate |
$135.66 |
| Max. Negotiated Rate |
$542.63 |
| Rate for Payer: Aetna Commercial |
$467.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$446.31
|
| Rate for Payer: Aetna Managed Medicare |
$135.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Anthem Medicare Advantage |
$135.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$135.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$135.66
|
| Rate for Payer: Cash Price |
$149.70
|
| Rate for Payer: Cash Price |
$149.70
|
| Rate for Payer: Cash Price |
$149.70
|
| Rate for Payer: Cigna Commercial |
$477.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$290.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.66
|
| Rate for Payer: Health EOS Commercial |
$461.87
|
| Rate for Payer: HFN Commercial |
$477.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$504.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$135.66
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$135.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$135.66
|
| Rate for Payer: Multiplan Commercial |
$415.17
|
| Rate for Payer: NAPHCARE Commercial |
$203.49
|
| Rate for Payer: Preferred Network Access Commercial |
$477.44
|
| Rate for Payer: Quartz Beloit One Network |
$254.29
|
| Rate for Payer: Quartz Commercial |
$337.32
|
| Rate for Payer: Quartz Medicare Advantage |
$135.66
|
| Rate for Payer: The Alliance Commercial |
$542.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$135.66
|
| Rate for Payer: United Healthcare PPO |
$389.22
|
| Rate for Payer: WEA Trust Commercial |
$285.43
|
| Rate for Payer: Wellcare Medicare |
$135.66
|
| Rate for Payer: WPS Commercial |
$384.38
|
|
|
Phase 3 Cardiac Rehab
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
CPT 93797
|
| Hospital Charge Code |
3052594
|
|
Hospital Revenue Code
|
943
|
| Min. Negotiated Rate |
$254.29 |
| Max. Negotiated Rate |
$477.44 |
| Rate for Payer: Aetna Commercial |
$467.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$446.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.05
|
| Rate for Payer: Cash Price |
$149.70
|
| Rate for Payer: Cigna Commercial |
$477.44
|
| Rate for Payer: Health EOS Commercial |
$461.87
|
| Rate for Payer: HFN Commercial |
$477.44
|
| Rate for Payer: Multiplan Commercial |
$415.17
|
| Rate for Payer: Preferred Network Access Commercial |
$477.44
|
| Rate for Payer: Quartz Beloit One Network |
$254.29
|
| Rate for Payer: Quartz Commercial |
$311.38
|
| Rate for Payer: WEA Trust Commercial |
$285.43
|
| Rate for Payer: WPS Commercial |
$384.38
|
|
|
Phase II COPD - Pulmonary Rehab
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
CPT 94626
|
| Hospital Charge Code |
2990161
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$189.06 |
| Max. Negotiated Rate |
$354.97 |
| Rate for Payer: Aetna Commercial |
$347.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.50
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$343.40
|
| Rate for Payer: HFN Commercial |
$354.97
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: Preferred Network Access Commercial |
$354.97
|
| Rate for Payer: Quartz Beloit One Network |
$189.06
|
| Rate for Payer: Quartz Commercial |
$231.50
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
Phase II COPD - Pulmonary Rehab
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
CPT 94626
|
| Hospital Charge Code |
2990161
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$62.09 |
| Max. Negotiated Rate |
$354.97 |
| Rate for Payer: Aetna Commercial |
$347.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$185.20
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$354.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$343.40
|
| Rate for Payer: HFN Commercial |
$354.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$354.97
|
| Rate for Payer: Quartz Beloit One Network |
$189.06
|
| Rate for Payer: Quartz Commercial |
$250.80
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
Phase II COPD - W/MTR Pulmonary Rehab 94626
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
CPT 94626
|
| Hospital Charge Code |
6121637
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$62.09 |
| Max. Negotiated Rate |
$354.97 |
| Rate for Payer: Aetna Commercial |
$347.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$185.20
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$354.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$343.40
|
| Rate for Payer: HFN Commercial |
$354.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$354.97
|
| Rate for Payer: Quartz Beloit One Network |
$189.06
|
| Rate for Payer: Quartz Commercial |
$250.80
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
Phase II COPD - W/MTR Pulmonary Rehab 94626
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
CPT 94626
|
| Hospital Charge Code |
6121637
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$189.06 |
| Max. Negotiated Rate |
$354.97 |
| Rate for Payer: Aetna Commercial |
$347.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.50
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$343.40
|
| Rate for Payer: HFN Commercial |
$354.97
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: Preferred Network Access Commercial |
$354.97
|
| Rate for Payer: Quartz Beloit One Network |
$189.06
|
| Rate for Payer: Quartz Commercial |
$231.50
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
Phase II COPD - W/O MTR Pulmonary Rehab 94625
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
CPT 94625
|
| Hospital Charge Code |
6121636
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$62.09 |
| Max. Negotiated Rate |
$248.35 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$160.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$123.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$118.81
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$160.89
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
Phase II COPD - W/O MTR Pulmonary Rehab 94625
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT 94625
|
| Hospital Charge Code |
6121636
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$121.28 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$148.51
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
Phase III - Pulmonary Rehab
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
3004212
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
Phase III - Pulmonary Rehab
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
3004212
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Aetna Managed Medicare |
$26.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.38
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: NAPHCARE Commercial |
$56.16
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$60.84
|
| Rate for Payer: Quartz Medicare Advantage |
$56.16
|
| Rate for Payer: The Alliance Commercial |
$46.80
|
| Rate for Payer: United Healthcare PPO |
$70.20
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
Phase II Non-COPD - Pulmonary Rehab
|
Facility
|
IP
|
$368.00
|
|
|
Service Code
|
HCPCS G0239
|
| Hospital Charge Code |
2990160
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$187.53 |
| Max. Negotiated Rate |
$352.10 |
| Rate for Payer: Aetna Commercial |
$344.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.84
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$352.10
|
| Rate for Payer: Health EOS Commercial |
$340.62
|
| Rate for Payer: HFN Commercial |
$352.10
|
| Rate for Payer: Multiplan Commercial |
$306.18
|
| Rate for Payer: Preferred Network Access Commercial |
$352.10
|
| Rate for Payer: Quartz Beloit One Network |
$187.53
|
| Rate for Payer: Quartz Commercial |
$229.63
|
| Rate for Payer: WEA Trust Commercial |
$210.50
|
| Rate for Payer: WPS Commercial |
$283.47
|
|
