|
pH, Venous
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$374.56 |
| Max. Negotiated Rate |
$703.25 |
| Rate for Payer: Aetna Commercial |
$687.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.13
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$703.25
|
| Rate for Payer: Health EOS Commercial |
$680.32
|
| Rate for Payer: HFN Commercial |
$703.25
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: Preferred Network Access Commercial |
$703.25
|
| Rate for Payer: Quartz Beloit One Network |
$374.56
|
| Rate for Payer: Quartz Commercial |
$458.64
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: WPS Commercial |
$566.17
|
|
|
pH, Venous
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$703.25 |
| Rate for Payer: Aetna Commercial |
$687.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Aetna Managed Medicare |
$11.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.99
|
| Rate for Payer: Anthem Medicare Advantage |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.44
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$703.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$427.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.44
|
| Rate for Payer: Health EOS Commercial |
$680.32
|
| Rate for Payer: HFN Commercial |
$703.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.44
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: NAPHCARE Commercial |
$17.16
|
| Rate for Payer: Preferred Network Access Commercial |
$703.25
|
| Rate for Payer: Quartz Beloit One Network |
$374.56
|
| Rate for Payer: Quartz Commercial |
$496.86
|
| Rate for Payer: Quartz Medicare Advantage |
$11.44
|
| Rate for Payer: The Alliance Commercial |
$45.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.44
|
| Rate for Payer: United Healthcare PPO |
$573.30
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: Wellcare Medicare |
$11.44
|
| Rate for Payer: WPS Commercial |
$566.17
|
|
|
pH, Venous
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$726.18 |
| Rate for Payer: Aetna Commercial |
$726.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Aetna Managed Medicare |
$11.44
|
| Rate for Payer: Anthem Medicare Advantage |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.44
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$726.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$382.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.44
|
| Rate for Payer: Health EOS Commercial |
$695.60
|
| Rate for Payer: HFN Commercial |
$726.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.44
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: NAPHCARE Commercial |
$17.16
|
| Rate for Payer: Preferred Network Access Commercial |
$726.18
|
| Rate for Payer: Quartz Beloit One Network |
$336.34
|
| Rate for Payer: Quartz Commercial |
$435.71
|
| Rate for Payer: Quartz Medicare Advantage |
$11.44
|
| Rate for Payer: The Alliance Commercial |
$45.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: WPS Commercial |
$50.34
|
|
|
Physical Performance Test Charges
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
CPT 97750 GP
|
| Hospital Charge Code |
2472554
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Physical Performance Test Charges
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
CPT 97750 GP
|
| Hospital Charge Code |
2472554
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: United Healthcare PPO |
$250.38
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Physical Perf Test - FCA Charges
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
3007746
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
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 |
$40.48 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$40.48
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$86.74
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$86.74
|
| Rate for Payer: The Alliance Commercial |
$72.28
|
| Rate for Payer: United Healthcare PPO |
$108.42
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
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 |
$170.93 |
| Max. Negotiated Rate |
$561.64 |
| Rate for Payer: Aetna Commercial |
$549.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.01
|
| Rate for Payer: Aetna Managed Medicare |
$170.93
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.55
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$561.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.63
|
| Rate for Payer: Health EOS Commercial |
$543.33
|
| Rate for Payer: HFN Commercial |
$561.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$488.38
|
| Rate for Payer: NAPHCARE Commercial |
$366.29
|
| Rate for Payer: Preferred Network Access Commercial |
$561.64
|
| Rate for Payer: Quartz Beloit One Network |
$299.14
|
| Rate for Payer: Quartz Commercial |
$396.81
|
| Rate for Payer: Quartz Medicare Advantage |
$366.29
|
| Rate for Payer: The Alliance Commercial |
$305.24
|
| Rate for Payer: United Healthcare PPO |
$457.86
|
| Rate for Payer: WEA Trust Commercial |
$335.76
|
| Rate for Payer: WPS Commercial |
$452.17
|
|
|
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 |
$299.14 |
| Max. Negotiated Rate |
$561.64 |
| Rate for Payer: Aetna Commercial |
$549.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.55
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$561.64
|
| Rate for Payer: Health EOS Commercial |
$543.33
|
| Rate for Payer: HFN Commercial |
$561.64
|
| Rate for Payer: Multiplan Commercial |
$488.38
|
| Rate for Payer: Preferred Network Access Commercial |
$561.64
|
| Rate for Payer: Quartz Beloit One Network |
$299.14
|
| Rate for Payer: Quartz Commercial |
$366.29
|
| Rate for Payer: WEA Trust Commercial |
$335.76
|
| Rate for Payer: WPS Commercial |
$452.17
|
|
|
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 |
$47.47 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$47.47
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.87
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$101.71
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$101.71
|
| Rate for Payer: The Alliance Commercial |
$84.76
|
| Rate for Payer: United Healthcare PPO |
$127.14
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
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 |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
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 |
$57.37 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Aetna Managed Medicare |
$57.37
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.65
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: NAPHCARE Commercial |
$122.93
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$133.17
|
| Rate for Payer: Quartz Medicare Advantage |
$122.93
|
| Rate for Payer: The Alliance Commercial |
$102.44
|
| Rate for Payer: United Healthcare PPO |
$153.66
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
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 |
$100.39 |
| Max. Negotiated Rate |
$188.49 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$122.93
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
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 |
$50.38 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Aetna Managed Medicare |
$50.38
|
| 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: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.69
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: NAPHCARE Commercial |
$107.95
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$116.95
|
| Rate for Payer: Quartz Medicare Advantage |
$107.95
|
| Rate for Payer: The Alliance Commercial |
$89.96
|
| Rate for Payer: United Healthcare PPO |
$134.94
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
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 |
$88.16 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$107.95
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
PHYSICAL THERAPY
|
Facility
|
OP
|
$89.10
|
|
|
Service Code
|
EAPG 00271
|
| Min. Negotiated Rate |
$85.67 |
| Max. Negotiated Rate |
$89.10 |
| Rate for Payer: Anthem Medicaid |
$85.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$85.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.67
|
| Rate for Payer: Dean Health Medicaid |
$85.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$85.67
|
| Rate for Payer: Managed Health Services Medicaid |
$89.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.67
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$85.67
|
| Rate for Payer: United Healthcare Medicaid |
$85.67
|
|
|
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 |
$56.39 |
| Max. Negotiated Rate |
$191.67 |
| Rate for Payer: Aetna Commercial |
$191.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.51
|
| Rate for Payer: Aetna Managed Medicare |
$56.39
|
| Rate for Payer: Anthem Medicare Advantage |
$56.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$56.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$56.39
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$191.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$100.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.39
|
| Rate for Payer: Health EOS Commercial |
$183.60
|
| Rate for Payer: HFN Commercial |
$191.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$185.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$185.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$56.39
|
| Rate for Payer: Multiplan Commercial |
$161.41
|
| Rate for Payer: NAPHCARE Commercial |
$84.58
|
| Rate for Payer: Preferred Network Access Commercial |
$191.67
|
| Rate for Payer: Quartz Beloit One Network |
$88.77
|
| Rate for Payer: Quartz Commercial |
$115.00
|
| Rate for Payer: Quartz Medicare Advantage |
$56.39
|
| Rate for Payer: The Alliance Commercial |
$155.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.39
|
| Rate for Payer: WEA Trust Commercial |
$110.97
|
| Rate for Payer: WPS Commercial |
$98.68
|
|
|
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 |
$32.95 |
| Max. Negotiated Rate |
$143.61 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$44.22
|
| Rate for Payer: Anthem Medicare Advantage |
$44.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$44.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$44.22
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$71.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.22
|
| Rate for Payer: Health EOS Commercial |
$68.14
|
| Rate for Payer: HFN Commercial |
$71.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$44.22
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$66.33
|
| Rate for Payer: Preferred Network Access Commercial |
$71.14
|
| Rate for Payer: Quartz Beloit One Network |
$32.95
|
| Rate for Payer: Quartz Commercial |
$42.68
|
| Rate for Payer: Quartz Medicare Advantage |
$44.22
|
| Rate for Payer: The Alliance Commercial |
$121.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.22
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$77.39
|
|
|
PHYSIO RING II ANNULOPLASTY
|
Facility
|
IP
|
$24,772.00
|
|
| Hospital Charge Code |
2965105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,623.81 |
| Max. Negotiated Rate |
$23,701.85 |
| Rate for Payer: Aetna Commercial |
$23,186.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,156.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,654.33
|
| Rate for Payer: Cash Price |
$7,431.60
|
| Rate for Payer: Cigna Commercial |
$23,701.85
|
| Rate for Payer: Health EOS Commercial |
$22,928.96
|
| Rate for Payer: HFN Commercial |
$23,701.85
|
| Rate for Payer: Multiplan Commercial |
$20,610.30
|
| Rate for Payer: Preferred Network Access Commercial |
$23,701.85
|
| Rate for Payer: Quartz Beloit One Network |
$12,623.81
|
| Rate for Payer: Quartz Commercial |
$15,457.73
|
| Rate for Payer: WEA Trust Commercial |
$14,169.58
|
| Rate for Payer: WPS Commercial |
$19,081.87
|
|
|
PHYSIO RING II ANNULOPLASTY
|
Facility
|
OP
|
$24,772.00
|
|
| Hospital Charge Code |
2965105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,213.61 |
| Max. Negotiated Rate |
$23,701.85 |
| Rate for Payer: Aetna Commercial |
$23,186.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,156.08
|
| Rate for Payer: Aetna Managed Medicare |
$7,213.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,745.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,881.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,366.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,654.33
|
| Rate for Payer: Cash Price |
$7,431.60
|
| Rate for Payer: Cigna Commercial |
$23,701.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,417.30
|
| Rate for Payer: Health EOS Commercial |
$22,928.96
|
| Rate for Payer: HFN Commercial |
$23,701.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,322.16
|
| Rate for Payer: Multiplan Commercial |
$20,610.30
|
| Rate for Payer: NAPHCARE Commercial |
$15,457.73
|
| Rate for Payer: Preferred Network Access Commercial |
$23,701.85
|
| Rate for Payer: Quartz Beloit One Network |
$12,623.81
|
| Rate for Payer: Quartz Commercial |
$16,745.87
|
| Rate for Payer: Quartz Medicare Advantage |
$15,457.73
|
| Rate for Payer: The Alliance Commercial |
$12,881.44
|
| Rate for Payer: WEA Trust Commercial |
$14,169.58
|
| Rate for Payer: WPS Commercial |
$19,081.87
|
|
|
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 |
$3.86 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Aetna Managed Medicare |
$10.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.86
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.08
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: NAPHCARE Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$24.34
|
| Rate for Payer: Quartz Medicare Advantage |
$22.46
|
| Rate for Payer: The Alliance Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$7.29
|
|
|
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 |
$18.35 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$22.46
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
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 |
$2.92 |
| Max. Negotiated Rate |
$35.57 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$35.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.92
|
| Rate for Payer: Health EOS Commercial |
$34.07
|
| Rate for Payer: HFN Commercial |
$35.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.68
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$35.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.47
|
| Rate for Payer: Quartz Commercial |
$21.34
|
| Rate for Payer: The Alliance Commercial |
$18.72
|
| Rate for Payer: United Healthcare Medicaid |
$2.92
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$7.29
|
|
|
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 |
$108.54 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$132.91
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
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 |
$106.33 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.33
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$143.99
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$166.14
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
