|
Pessary, non rubber, any type A4562
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
Pessary, non rubber, any type A4562
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$29.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$63.00
|
| Rate for Payer: The Alliance Commercial |
$420.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
PESSARY SHAATZ/FOLD PESSARY 3-1/4 MXKPSH3-1/4
|
Facility
|
IP
|
$991.00
|
|
| Hospital Charge Code |
3072500
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$485.59 |
| Max. Negotiated Rate |
$911.72 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$852.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$594.60
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
PESSARY SHAATZ/FOLD PESSARY 3-1/4 MXKPSH3-1/4
|
Facility
|
OP
|
$991.00
|
|
| Hospital Charge Code |
3072500
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$277.48 |
| Max. Negotiated Rate |
$3,964.00 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$852.26
|
| Rate for Payer: Aetna Managed Medicare |
$277.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$644.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$495.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$475.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$554.56
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$743.25
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$644.15
|
| Rate for Payer: Quartz Medicare Advantage |
$594.60
|
| Rate for Payer: The Alliance Commercial |
$3,964.00
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Facility
|
IP
|
$3,199.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
2587013
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,567.51 |
| Max. Negotiated Rate |
$2,943.08 |
| Rate for Payer: Aetna Commercial |
$2,879.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,751.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,695.47
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cigna Commercial |
$2,943.08
|
| Rate for Payer: Health EOS Commercial |
$2,847.11
|
| Rate for Payer: HFN Commercial |
$2,943.08
|
| Rate for Payer: Multiplan Commercial |
$2,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,919.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,943.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,567.51
|
| Rate for Payer: Quartz Commercial |
$1,919.40
|
| Rate for Payer: WEA Trust Commercial |
$1,759.45
|
| Rate for Payer: WPS Commercial |
$2,369.50
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Facility
|
OP
|
$3,199.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
2587013
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,546.32 |
| Max. Negotiated Rate |
$6,185.28 |
| Rate for Payer: Aetna Commercial |
$2,879.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,751.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,546.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,079.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,273.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,695.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,546.32
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cigna Commercial |
$2,943.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,790.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$2,847.11
|
| Rate for Payer: HFN Commercial |
$2,943.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,752.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,546.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,546.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,546.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,546.32
|
| Rate for Payer: Multiplan Commercial |
$2,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$2,943.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,567.51
|
| Rate for Payer: Quartz Commercial |
$2,079.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,546.32
|
| Rate for Payer: The Alliance Commercial |
$6,185.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,546.32
|
| Rate for Payer: United Healthcare PPO |
$2,399.25
|
| Rate for Payer: WEA Trust Commercial |
$1,759.45
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$2,369.50
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Facility
|
OP
|
$3,076.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
627674
|
| Min. Negotiated Rate |
$1,476.48 |
| Max. Negotiated Rate |
$6,185.28 |
| Rate for Payer: Aetna Commercial |
$2,768.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,645.36
|
| Rate for Payer: Aetna Managed Medicare |
$1,546.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,999.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,538.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,476.48
|
| Rate for Payer: Anthem Medicare Advantage |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,630.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,546.32
|
| Rate for Payer: Cash Price |
$922.80
|
| Rate for Payer: Cash Price |
$922.80
|
| Rate for Payer: Cigna Commercial |
$2,829.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,721.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$2,737.64
|
| Rate for Payer: HFN Commercial |
$2,829.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,752.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,546.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,546.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,546.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,546.32
|
| Rate for Payer: Multiplan Commercial |
$2,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$2,829.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,507.24
|
| Rate for Payer: Quartz Commercial |
$1,999.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,546.32
|
| Rate for Payer: The Alliance Commercial |
$6,185.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,546.32
|
| Rate for Payer: WEA Trust Commercial |
$1,691.80
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$2,278.39
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Professional
|
Both
|
$3,199.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
2587013
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,407.56 |
| Max. Negotiated Rate |
$8,231.85 |
| Rate for Payer: Aetna Commercial |
$3,039.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,751.14
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cigna Commercial |
$3,039.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,599.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,919.40
|
| Rate for Payer: Health EOS Commercial |
$2,911.09
|
| Rate for Payer: HFN Commercial |
$3,039.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,231.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,231.85
|
| Rate for Payer: Multiplan Commercial |
$2,559.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,039.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,407.56
|
| Rate for Payer: Quartz Commercial |
$1,823.43
|
| Rate for Payer: The Alliance Commercial |
$1,599.50
|
| Rate for Payer: WEA Trust Commercial |
$1,759.45
|
| Rate for Payer: WPS Commercial |
$2,369.50
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Facility
|
IP
|
$3,076.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
627674
|
| Min. Negotiated Rate |
$1,507.24 |
| Max. Negotiated Rate |
$2,829.92 |
| Rate for Payer: Aetna Commercial |
$2,768.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,645.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,630.28
|
| Rate for Payer: Cash Price |
$922.80
|
| Rate for Payer: Cigna Commercial |
$2,829.92
|
| Rate for Payer: Health EOS Commercial |
$2,737.64
|
| Rate for Payer: HFN Commercial |
$2,829.92
|
| Rate for Payer: Multiplan Commercial |
$2,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,845.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,829.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,507.24
|
| Rate for Payer: Quartz Commercial |
$1,845.60
|
| Rate for Payer: WEA Trust Commercial |
$1,691.80
|
| Rate for Payer: WPS Commercial |
$2,278.39
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Professional
|
Both
|
$3,076.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
627674
|
| Min. Negotiated Rate |
$1,353.44 |
| Max. Negotiated Rate |
$8,231.85 |
| Rate for Payer: Aetna Commercial |
$2,922.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,645.36
|
| Rate for Payer: Cash Price |
$922.80
|
| Rate for Payer: Cash Price |
$922.80
|
| Rate for Payer: Cigna Commercial |
$2,922.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,538.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,845.60
|
| Rate for Payer: Health EOS Commercial |
$2,799.16
|
| Rate for Payer: HFN Commercial |
$2,922.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,231.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,231.85
|
| Rate for Payer: Multiplan Commercial |
$2,460.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,922.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,353.44
|
| Rate for Payer: Quartz Commercial |
$1,753.32
|
| Rate for Payer: The Alliance Commercial |
$1,538.00
|
| Rate for Payer: WEA Trust Commercial |
$1,691.80
|
| Rate for Payer: WPS Commercial |
$2,278.39
|
|
|
PET/CT Axumin
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
5428942
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,629.52 |
| Max. Negotiated Rate |
$8,692.16 |
| Rate for Payer: Aetna Commercial |
$8,503.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,007.44
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,692.16
|
| Rate for Payer: Health EOS Commercial |
$8,408.72
|
| Rate for Payer: HFN Commercial |
$8,692.16
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,668.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,692.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,629.52
|
| Rate for Payer: Quartz Commercial |
$5,668.80
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
|
PET/CT Axumin
|
Professional
|
Both
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
5428942
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,157.12 |
| Max. Negotiated Rate |
$10,386.60 |
| Rate for Payer: Aetna Commercial |
$8,975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,975.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,724.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,668.80
|
| Rate for Payer: Health EOS Commercial |
$8,597.68
|
| Rate for Payer: HFN Commercial |
$8,975.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,386.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,386.60
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,975.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,157.12
|
| Rate for Payer: Quartz Commercial |
$5,385.36
|
| Rate for Payer: The Alliance Commercial |
$4,724.00
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
|
PET/CT Axumin
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
5428942
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,546.32 |
| Max. Negotiated Rate |
$8,692.16 |
| Rate for Payer: Aetna Commercial |
$8,503.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,546.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,079.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,273.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,007.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,546.32
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,692.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,287.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$8,408.72
|
| Rate for Payer: HFN Commercial |
$8,692.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,752.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,546.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,546.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,546.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,546.32
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$8,692.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,629.52
|
| Rate for Payer: Quartz Commercial |
$6,141.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,546.32
|
| Rate for Payer: The Alliance Commercial |
$6,185.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,546.32
|
| Rate for Payer: United Healthcare PPO |
$7,086.00
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
|
PET/CT Breast CA Initial Tx
|
Professional
|
Both
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587026
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,157.12 |
| Max. Negotiated Rate |
$10,386.60 |
| Rate for Payer: Aetna Commercial |
$8,975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,975.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,724.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,668.80
|
| Rate for Payer: Health EOS Commercial |
$8,597.68
|
| Rate for Payer: HFN Commercial |
$8,975.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,386.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,386.60
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,975.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,157.12
|
| Rate for Payer: Quartz Commercial |
$5,385.36
|
| Rate for Payer: The Alliance Commercial |
$4,724.00
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
|
PET/CT Breast CA Initial Tx
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587026
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,546.32 |
| Max. Negotiated Rate |
$8,692.16 |
| Rate for Payer: Aetna Commercial |
$8,503.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,546.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,079.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,273.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,007.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,546.32
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,692.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,287.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$8,408.72
|
| Rate for Payer: HFN Commercial |
$8,692.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,752.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,546.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,546.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,546.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,546.32
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$8,692.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,629.52
|
| Rate for Payer: Quartz Commercial |
$6,141.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,546.32
|
| Rate for Payer: The Alliance Commercial |
$6,185.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,546.32
|
| Rate for Payer: United Healthcare PPO |
$7,086.00
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
|
PET/CT Breast CA Initial Tx
|
Facility
|
IP
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
675715
|
| Min. Negotiated Rate |
$4,268.39 |
| Max. Negotiated Rate |
$8,014.12 |
| Rate for Payer: Aetna Commercial |
$7,839.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,491.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,616.83
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cigna Commercial |
$8,014.12
|
| Rate for Payer: Health EOS Commercial |
$7,752.79
|
| Rate for Payer: HFN Commercial |
$8,014.12
|
| Rate for Payer: Multiplan Commercial |
$6,968.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,226.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,014.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,268.39
|
| Rate for Payer: Quartz Commercial |
$5,226.60
|
| Rate for Payer: WEA Trust Commercial |
$4,791.05
|
| Rate for Payer: WPS Commercial |
$6,452.24
|
|
|
PET/CT Breast CA Initial Tx
|
Professional
|
Both
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
675715
|
| Min. Negotiated Rate |
$3,832.84 |
| Max. Negotiated Rate |
$10,386.60 |
| Rate for Payer: Aetna Commercial |
$8,275.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,491.46
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cigna Commercial |
$8,275.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,355.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,226.60
|
| Rate for Payer: Health EOS Commercial |
$7,927.01
|
| Rate for Payer: HFN Commercial |
$8,275.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,386.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,386.60
|
| Rate for Payer: Multiplan Commercial |
$6,968.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,275.45
|
| Rate for Payer: Quartz Beloit One Network |
$3,832.84
|
| Rate for Payer: Quartz Commercial |
$4,965.27
|
| Rate for Payer: The Alliance Commercial |
$4,355.50
|
| Rate for Payer: WEA Trust Commercial |
$4,791.05
|
| Rate for Payer: WPS Commercial |
$6,452.24
|
|
|
PET/CT Breast CA Initial Tx
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587026
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,629.52 |
| Max. Negotiated Rate |
$8,692.16 |
| Rate for Payer: Aetna Commercial |
$8,503.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,007.44
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,692.16
|
| Rate for Payer: Health EOS Commercial |
$8,408.72
|
| Rate for Payer: HFN Commercial |
$8,692.16
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,668.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,692.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,629.52
|
| Rate for Payer: Quartz Commercial |
$5,668.80
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
|
PET/CT Breast CA Initial Tx
|
Facility
|
OP
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
675715
|
| Min. Negotiated Rate |
$1,546.32 |
| Max. Negotiated Rate |
$8,014.12 |
| Rate for Payer: Aetna Commercial |
$7,839.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,491.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,546.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,662.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,181.28
|
| Rate for Payer: Anthem Medicare Advantage |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,616.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,546.32
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cigna Commercial |
$8,014.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,874.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$7,752.79
|
| Rate for Payer: HFN Commercial |
$8,014.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,752.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,546.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,546.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,546.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,546.32
|
| Rate for Payer: Multiplan Commercial |
$6,968.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$8,014.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,268.39
|
| Rate for Payer: Quartz Commercial |
$5,662.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,546.32
|
| Rate for Payer: The Alliance Commercial |
$6,185.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,546.32
|
| Rate for Payer: WEA Trust Commercial |
$4,791.05
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$6,452.24
|
|
|
PET/CT Breast CA Sub Tx
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587028
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,546.32 |
| Max. Negotiated Rate |
$8,692.16 |
| Rate for Payer: Aetna Commercial |
$8,503.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,546.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,079.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,273.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,007.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,546.32
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,692.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,287.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$8,408.72
|
| Rate for Payer: HFN Commercial |
$8,692.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,752.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,546.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,546.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,546.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,546.32
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$8,692.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,629.52
|
| Rate for Payer: Quartz Commercial |
$6,141.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,546.32
|
| Rate for Payer: The Alliance Commercial |
$6,185.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,546.32
|
| Rate for Payer: United Healthcare PPO |
$7,086.00
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
|
PET/CT Breast CA Sub Tx
|
Professional
|
Both
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
661635
|
| Min. Negotiated Rate |
$3,832.84 |
| Max. Negotiated Rate |
$10,386.60 |
| Rate for Payer: Aetna Commercial |
$8,275.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,491.46
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cigna Commercial |
$8,275.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,355.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,226.60
|
| Rate for Payer: Health EOS Commercial |
$7,927.01
|
| Rate for Payer: HFN Commercial |
$8,275.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,386.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,386.60
|
| Rate for Payer: Multiplan Commercial |
$6,968.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,275.45
|
| Rate for Payer: Quartz Beloit One Network |
$3,832.84
|
| Rate for Payer: Quartz Commercial |
$4,965.27
|
| Rate for Payer: The Alliance Commercial |
$4,355.50
|
| Rate for Payer: WEA Trust Commercial |
$4,791.05
|
| Rate for Payer: WPS Commercial |
$6,452.24
|
|
|
PET/CT Breast CA Sub Tx
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587028
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,629.52 |
| Max. Negotiated Rate |
$8,692.16 |
| Rate for Payer: Aetna Commercial |
$8,503.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,007.44
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,692.16
|
| Rate for Payer: Health EOS Commercial |
$8,408.72
|
| Rate for Payer: HFN Commercial |
$8,692.16
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,668.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,692.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,629.52
|
| Rate for Payer: Quartz Commercial |
$5,668.80
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
|
PET/CT Breast CA Sub Tx
|
Facility
|
IP
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
661635
|
| Min. Negotiated Rate |
$4,268.39 |
| Max. Negotiated Rate |
$8,014.12 |
| Rate for Payer: Aetna Commercial |
$7,839.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,491.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,616.83
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cigna Commercial |
$8,014.12
|
| Rate for Payer: Health EOS Commercial |
$7,752.79
|
| Rate for Payer: HFN Commercial |
$8,014.12
|
| Rate for Payer: Multiplan Commercial |
$6,968.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,226.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,014.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,268.39
|
| Rate for Payer: Quartz Commercial |
$5,226.60
|
| Rate for Payer: WEA Trust Commercial |
$4,791.05
|
| Rate for Payer: WPS Commercial |
$6,452.24
|
|
|
PET/CT Breast CA Sub Tx
|
Facility
|
OP
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
661635
|
| Min. Negotiated Rate |
$1,546.32 |
| Max. Negotiated Rate |
$8,014.12 |
| Rate for Payer: Aetna Commercial |
$7,839.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,491.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,546.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,662.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,181.28
|
| Rate for Payer: Anthem Medicare Advantage |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,616.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,546.32
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cash Price |
$2,613.30
|
| Rate for Payer: Cigna Commercial |
$8,014.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,874.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$7,752.79
|
| Rate for Payer: HFN Commercial |
$8,014.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,752.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,546.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,546.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,546.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,546.32
|
| Rate for Payer: Multiplan Commercial |
$6,968.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$8,014.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,268.39
|
| Rate for Payer: Quartz Commercial |
$5,662.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,546.32
|
| Rate for Payer: The Alliance Commercial |
$6,185.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,546.32
|
| Rate for Payer: WEA Trust Commercial |
$4,791.05
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$6,452.24
|
|
|
PET/CT Breast CA Sub Tx
|
Professional
|
Both
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587028
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,157.12 |
| Max. Negotiated Rate |
$10,386.60 |
| Rate for Payer: Aetna Commercial |
$8,975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,125.28
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$8,975.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,724.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,668.80
|
| Rate for Payer: Health EOS Commercial |
$8,597.68
|
| Rate for Payer: HFN Commercial |
$8,975.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,386.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,386.60
|
| Rate for Payer: Multiplan Commercial |
$7,558.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,975.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,157.12
|
| Rate for Payer: Quartz Commercial |
$5,385.36
|
| Rate for Payer: The Alliance Commercial |
$4,724.00
|
| Rate for Payer: WEA Trust Commercial |
$5,196.40
|
| Rate for Payer: WPS Commercial |
$6,998.13
|
|
