|
Phosphorus Level
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 84100
|
| Hospital Charge Code |
633803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$4.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.18
|
| Rate for Payer: Anthem Medicare Advantage |
$4.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.93
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.93
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.93
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.93
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$7.39
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$55.43
|
| Rate for Payer: Quartz Medicare Advantage |
$4.93
|
| Rate for Payer: The Alliance Commercial |
$19.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.93
|
| Rate for Payer: United Healthcare PPO |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: Wellcare Medicare |
$4.93
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
Phosphorus Level
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
CPT 84100
|
| Hospital Charge Code |
633803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$81.02 |
| Rate for Payer: Aetna Commercial |
$81.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$4.93
|
| Rate for Payer: Anthem Medicare Advantage |
$4.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.93
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$81.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.93
|
| Rate for Payer: Health EOS Commercial |
$77.60
|
| Rate for Payer: HFN Commercial |
$81.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.93
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$7.39
|
| Rate for Payer: Preferred Network Access Commercial |
$81.02
|
| Rate for Payer: Quartz Beloit One Network |
$37.52
|
| Rate for Payer: Quartz Commercial |
$48.61
|
| Rate for Payer: Quartz Medicare Advantage |
$4.93
|
| Rate for Payer: The Alliance Commercial |
$19.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.93
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$21.69
|
|
|
Phosphorus, Urine
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
CPT 84105
|
| Hospital Charge Code |
5474690
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$19.34
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
Phosphorus, Urine
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
CPT 84105
|
| Hospital Charge Code |
5474690
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$6.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.98
|
| Rate for Payer: Anthem Medicare Advantage |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.01
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.01
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.01
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$9.02
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$20.96
|
| Rate for Payer: Quartz Medicare Advantage |
$6.01
|
| Rate for Payer: The Alliance Commercial |
$24.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.01
|
| Rate for Payer: United Healthcare PPO |
$24.18
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: Wellcare Medicare |
$6.01
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
Phosphorus, Urine
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
CPT 84105
|
| Hospital Charge Code |
5474690
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$30.63 |
| Rate for Payer: Aetna Commercial |
$30.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$6.01
|
| Rate for Payer: Anthem Medicare Advantage |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.01
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$30.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.01
|
| Rate for Payer: Health EOS Commercial |
$29.34
|
| Rate for Payer: HFN Commercial |
$30.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.01
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$9.02
|
| Rate for Payer: Preferred Network Access Commercial |
$30.63
|
| Rate for Payer: Quartz Beloit One Network |
$14.19
|
| Rate for Payer: Quartz Commercial |
$18.38
|
| Rate for Payer: Quartz Medicare Advantage |
$6.01
|
| Rate for Payer: The Alliance Commercial |
$23.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.01
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$26.45
|
|
|
Photocoagulation, Prophylaxis Of Retinal Detachment
|
Professional
|
Both
|
$2,112.00
|
|
|
Service Code
|
CPT 67145
|
| Hospital Charge Code |
1188906
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$187.11 |
| Max. Negotiated Rate |
$2,086.66 |
| Rate for Payer: Aetna Commercial |
$2,086.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,888.97
|
| Rate for Payer: Aetna Managed Medicare |
$187.11
|
| Rate for Payer: Anthem Medicare Advantage |
$187.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$187.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$187.11
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cigna Commercial |
$2,086.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$427.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.11
|
| Rate for Payer: Health EOS Commercial |
$1,998.80
|
| Rate for Payer: HFN Commercial |
$2,086.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,734.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,734.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$187.11
|
| Rate for Payer: Multiplan Commercial |
$1,757.18
|
| Rate for Payer: NAPHCARE Commercial |
$280.66
|
| Rate for Payer: Preferred Network Access Commercial |
$2,086.66
|
| Rate for Payer: Quartz Beloit One Network |
$966.45
|
| Rate for Payer: Quartz Commercial |
$1,251.99
|
| Rate for Payer: Quartz Medicare Advantage |
$187.11
|
| Rate for Payer: The Alliance Commercial |
$795.20
|
| Rate for Payer: United Healthcare Medicaid |
$427.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$187.11
|
| Rate for Payer: WEA Trust Commercial |
$1,208.06
|
| Rate for Payer: WPS Commercial |
$841.98
|
|
|
Phototherapy Double - Daily Charges
|
Facility
|
IP
|
$602.00
|
|
| Hospital Charge Code |
3003959
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$306.78 |
| Max. Negotiated Rate |
$575.99 |
| Rate for Payer: Aetna Commercial |
$563.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.82
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$575.99
|
| Rate for Payer: Health EOS Commercial |
$557.21
|
| Rate for Payer: HFN Commercial |
$575.99
|
| Rate for Payer: Multiplan Commercial |
$500.86
|
| Rate for Payer: Preferred Network Access Commercial |
$575.99
|
| Rate for Payer: Quartz Beloit One Network |
$306.78
|
| Rate for Payer: Quartz Commercial |
$375.65
|
| Rate for Payer: WEA Trust Commercial |
$344.34
|
| Rate for Payer: WPS Commercial |
$463.72
|
|
|
Phototherapy Double - Daily Charges
|
Facility
|
OP
|
$602.00
|
|
| Hospital Charge Code |
3003959
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$175.30 |
| Max. Negotiated Rate |
$575.99 |
| Rate for Payer: Aetna Commercial |
$563.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.43
|
| Rate for Payer: Aetna Managed Medicare |
$175.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$406.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$313.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$300.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.82
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$575.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$350.36
|
| Rate for Payer: Health EOS Commercial |
$557.21
|
| Rate for Payer: HFN Commercial |
$575.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.56
|
| Rate for Payer: Multiplan Commercial |
$500.86
|
| Rate for Payer: NAPHCARE Commercial |
$375.65
|
| Rate for Payer: Preferred Network Access Commercial |
$575.99
|
| Rate for Payer: Quartz Beloit One Network |
$306.78
|
| Rate for Payer: Quartz Commercial |
$406.95
|
| Rate for Payer: Quartz Medicare Advantage |
$375.65
|
| Rate for Payer: The Alliance Commercial |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$344.34
|
| Rate for Payer: WPS Commercial |
$463.72
|
|
|
Phototherapy Double - Nursery Daily Charges
|
Facility
|
OP
|
$602.00
|
|
| Hospital Charge Code |
3003951
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$175.30 |
| Max. Negotiated Rate |
$575.99 |
| Rate for Payer: Aetna Commercial |
$563.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.43
|
| Rate for Payer: Aetna Managed Medicare |
$175.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$406.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$313.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$300.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.82
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$575.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$350.36
|
| Rate for Payer: Health EOS Commercial |
$557.21
|
| Rate for Payer: HFN Commercial |
$575.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.56
|
| Rate for Payer: Multiplan Commercial |
$500.86
|
| Rate for Payer: NAPHCARE Commercial |
$375.65
|
| Rate for Payer: Preferred Network Access Commercial |
$575.99
|
| Rate for Payer: Quartz Beloit One Network |
$306.78
|
| Rate for Payer: Quartz Commercial |
$406.95
|
| Rate for Payer: Quartz Medicare Advantage |
$375.65
|
| Rate for Payer: The Alliance Commercial |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$344.34
|
| Rate for Payer: WPS Commercial |
$463.72
|
|
|
Phototherapy Double - Nursery Daily Charges
|
Facility
|
IP
|
$602.00
|
|
| Hospital Charge Code |
3003951
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$306.78 |
| Max. Negotiated Rate |
$575.99 |
| Rate for Payer: Aetna Commercial |
$563.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.82
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$575.99
|
| Rate for Payer: Health EOS Commercial |
$557.21
|
| Rate for Payer: HFN Commercial |
$575.99
|
| Rate for Payer: Multiplan Commercial |
$500.86
|
| Rate for Payer: Preferred Network Access Commercial |
$575.99
|
| Rate for Payer: Quartz Beloit One Network |
$306.78
|
| Rate for Payer: Quartz Commercial |
$375.65
|
| Rate for Payer: WEA Trust Commercial |
$344.34
|
| Rate for Payer: WPS Commercial |
$463.72
|
|
|
Phototherapy Single - Daily Charges
|
Facility
|
IP
|
$259.00
|
|
| Hospital Charge Code |
3003958
|
|
Hospital Revenue Code
|
121
|
| Min. Negotiated Rate |
$131.99 |
| Max. Negotiated Rate |
$247.81 |
| Rate for Payer: Aetna Commercial |
$242.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.76
|
| Rate for Payer: Cash Price |
$77.70
|
| Rate for Payer: Cigna Commercial |
$247.81
|
| Rate for Payer: Health EOS Commercial |
$239.73
|
| Rate for Payer: HFN Commercial |
$247.81
|
| Rate for Payer: Multiplan Commercial |
$215.49
|
| Rate for Payer: Preferred Network Access Commercial |
$247.81
|
| Rate for Payer: Quartz Beloit One Network |
$131.99
|
| Rate for Payer: Quartz Commercial |
$161.62
|
| Rate for Payer: WEA Trust Commercial |
$148.15
|
| Rate for Payer: WPS Commercial |
$199.51
|
|
|
Phototherapy Single - Nursery Daily Charges
|
Facility
|
OP
|
$275.00
|
|
| Hospital Charge Code |
3003950
|
|
Hospital Revenue Code
|
231
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$263.12 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Aetna Managed Medicare |
$80.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$143.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$137.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.05
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$214.50
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$185.90
|
| Rate for Payer: Quartz Medicare Advantage |
$171.60
|
| Rate for Payer: The Alliance Commercial |
$143.00
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.83
|
|
|
Phototherapy Single - Nursery Daily Charges
|
Facility
|
IP
|
$275.00
|
|
| Hospital Charge Code |
3003950
|
|
Hospital Revenue Code
|
231
|
| Min. Negotiated Rate |
$140.14 |
| Max. Negotiated Rate |
$263.12 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.83
|
|
|
Phototherapy Triple - Daily Charges
|
Facility
|
IP
|
$904.00
|
|
| Hospital Charge Code |
3003957
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$460.68 |
| Max. Negotiated Rate |
$864.95 |
| Rate for Payer: Aetna Commercial |
$846.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.28
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$864.95
|
| Rate for Payer: Health EOS Commercial |
$836.74
|
| Rate for Payer: HFN Commercial |
$864.95
|
| Rate for Payer: Multiplan Commercial |
$752.13
|
| Rate for Payer: Preferred Network Access Commercial |
$864.95
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$564.10
|
| Rate for Payer: WEA Trust Commercial |
$517.09
|
| Rate for Payer: WPS Commercial |
$696.35
|
|
|
Phototherapy Triple - Daily Charges
|
Facility
|
OP
|
$904.00
|
|
| Hospital Charge Code |
3003957
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$263.24 |
| Max. Negotiated Rate |
$864.95 |
| Rate for Payer: Aetna Commercial |
$846.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.54
|
| Rate for Payer: Aetna Managed Medicare |
$263.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.28
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$864.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.13
|
| Rate for Payer: Health EOS Commercial |
$836.74
|
| Rate for Payer: HFN Commercial |
$864.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.12
|
| Rate for Payer: Multiplan Commercial |
$752.13
|
| Rate for Payer: NAPHCARE Commercial |
$564.10
|
| Rate for Payer: Preferred Network Access Commercial |
$864.95
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$611.10
|
| Rate for Payer: Quartz Medicare Advantage |
$564.10
|
| Rate for Payer: The Alliance Commercial |
$470.08
|
| Rate for Payer: WEA Trust Commercial |
$517.09
|
| Rate for Payer: WPS Commercial |
$696.35
|
|
|
Phototherapy Triple - Nursery Daily Charges
|
Facility
|
IP
|
$904.00
|
|
| Hospital Charge Code |
3003949
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$460.68 |
| Max. Negotiated Rate |
$864.95 |
| Rate for Payer: Aetna Commercial |
$846.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.28
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$864.95
|
| Rate for Payer: Health EOS Commercial |
$836.74
|
| Rate for Payer: HFN Commercial |
$864.95
|
| Rate for Payer: Multiplan Commercial |
$752.13
|
| Rate for Payer: Preferred Network Access Commercial |
$864.95
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$564.10
|
| Rate for Payer: WEA Trust Commercial |
$517.09
|
| Rate for Payer: WPS Commercial |
$696.35
|
|
|
Phototherapy Triple - Nursery Daily Charges
|
Facility
|
OP
|
$904.00
|
|
| Hospital Charge Code |
3003949
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$263.24 |
| Max. Negotiated Rate |
$864.95 |
| Rate for Payer: Aetna Commercial |
$846.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.54
|
| Rate for Payer: Aetna Managed Medicare |
$263.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.28
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$864.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.13
|
| Rate for Payer: Health EOS Commercial |
$836.74
|
| Rate for Payer: HFN Commercial |
$864.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.12
|
| Rate for Payer: Multiplan Commercial |
$752.13
|
| Rate for Payer: NAPHCARE Commercial |
$564.10
|
| Rate for Payer: Preferred Network Access Commercial |
$864.95
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$611.10
|
| Rate for Payer: Quartz Medicare Advantage |
$564.10
|
| Rate for Payer: The Alliance Commercial |
$470.08
|
| Rate for Payer: WEA Trust Commercial |
$517.09
|
| Rate for Payer: WPS Commercial |
$696.35
|
|
|
PHOTOVAPORIZATION PROSTATE/BLADDER
|
Facility
|
OP
|
$12,167.00
|
|
|
Service Code
|
CPT 52648
|
| Hospital Charge Code |
2960194
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$22,570.79 |
| Rate for Payer: Aetna Commercial |
$11,388.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,882.16
|
| Rate for Payer: Aetna Managed Medicare |
$5,642.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$5,642.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,706.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,642.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,642.70
|
| 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 |
$11,641.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,642.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,642.70
|
| Rate for Payer: Health EOS Commercial |
$11,261.78
|
| Rate for Payer: HFN Commercial |
$11,641.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,990.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,642.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,642.70
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,642.70
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,642.70
|
| Rate for Payer: Multiplan Commercial |
$10,122.94
|
| Rate for Payer: NAPHCARE Commercial |
$8,464.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,641.39
|
| Rate for Payer: Quartz Beloit One Network |
$6,200.30
|
| Rate for Payer: Quartz Commercial |
$8,224.89
|
| Rate for Payer: Quartz Medicare Advantage |
$5,642.70
|
| Rate for Payer: The Alliance Commercial |
$22,570.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,642.70
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: WEA Trust Commercial |
$6,959.52
|
| Rate for Payer: Wellcare Medicare |
$5,642.70
|
| Rate for Payer: WPS Commercial |
$9,372.24
|
|
|
PHOTOVAPORIZATION PROSTATE/BLADDER
|
Facility
|
IP
|
$12,167.00
|
|
|
Service Code
|
CPT 52648
|
| Hospital Charge Code |
2960194
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,200.30 |
| Max. Negotiated Rate |
$11,641.39 |
| Rate for Payer: Aetna Commercial |
$11,388.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,882.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,706.45
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cigna Commercial |
$11,641.39
|
| Rate for Payer: Health EOS Commercial |
$11,261.78
|
| Rate for Payer: HFN Commercial |
$11,641.39
|
| Rate for Payer: Multiplan Commercial |
$10,122.94
|
| Rate for Payer: Preferred Network Access Commercial |
$11,641.39
|
| Rate for Payer: Quartz Beloit One Network |
$6,200.30
|
| Rate for Payer: Quartz Commercial |
$7,592.21
|
| Rate for Payer: WEA Trust Commercial |
$6,959.52
|
| Rate for Payer: WPS Commercial |
$9,372.24
|
|
|
pH, Pleural Fluid
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$36.19
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
pH, Pleural Fluid
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.18
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$39.21
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: United Healthcare PPO |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: Wellcare Medicare |
$3.72
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
pH, Pleural Fluid
|
Professional
|
Both
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$57.30 |
| Rate for Payer: Aetna Commercial |
$57.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$57.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$54.89
|
| Rate for Payer: HFN Commercial |
$57.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$57.30
|
| Rate for Payer: Quartz Beloit One Network |
$26.54
|
| Rate for Payer: Quartz Commercial |
$34.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$16.38
|
|
|
pH, Urine
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.18
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: United Healthcare PPO |
$17.16
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: Wellcare Medicare |
$3.72
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
pH, Urine
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
pH, Urine
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.38
|
|
