|
PET/CT Sub Treatment Unlisted
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587062
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,504.86 |
| Max. Negotiated Rate |
$9,039.85 |
| Rate for Payer: Aetna Commercial |
$8,843.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,450.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,504.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,242.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,583.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,403.92
|
| Rate for Payer: Anthem Medicare Advantage |
$1,504.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,207.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,504.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,504.86
|
| 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 |
$9,039.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,504.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,498.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,504.86
|
| Rate for Payer: Health EOS Commercial |
$8,745.07
|
| Rate for Payer: HFN Commercial |
$9,039.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,598.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,504.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,504.86
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,504.86
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,504.86
|
| Rate for Payer: Multiplan Commercial |
$7,860.74
|
| Rate for Payer: NAPHCARE Commercial |
$2,257.29
|
| Rate for Payer: Preferred Network Access Commercial |
$9,039.85
|
| Rate for Payer: Quartz Beloit One Network |
$4,814.70
|
| Rate for Payer: Quartz Commercial |
$6,386.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,504.86
|
| Rate for Payer: The Alliance Commercial |
$6,019.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,504.86
|
| Rate for Payer: United Healthcare PPO |
$7,369.44
|
| Rate for Payer: WEA Trust Commercial |
$5,404.26
|
| Rate for Payer: Wellcare Medicare |
$1,504.86
|
| Rate for Payer: WPS Commercial |
$7,277.79
|
|
|
PET/CT Sub Treatment Unlisted
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587062
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,814.70 |
| Max. Negotiated Rate |
$9,039.85 |
| Rate for Payer: Aetna Commercial |
$8,843.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,450.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,207.74
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$9,039.85
|
| Rate for Payer: Health EOS Commercial |
$8,745.07
|
| Rate for Payer: HFN Commercial |
$9,039.85
|
| Rate for Payer: Multiplan Commercial |
$7,860.74
|
| Rate for Payer: Preferred Network Access Commercial |
$9,039.85
|
| Rate for Payer: Quartz Beloit One Network |
$4,814.70
|
| Rate for Payer: Quartz Commercial |
$5,895.55
|
| Rate for Payer: WEA Trust Commercial |
$5,404.26
|
| Rate for Payer: WPS Commercial |
$7,277.79
|
|
|
PET/CT Unlisted Whole Body
|
Professional
|
Both
|
$9,448.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2587065
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,323.40 |
| Max. Negotiated Rate |
$10,805.74 |
| Rate for Payer: Aetna Commercial |
$9,334.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,450.29
|
| 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 |
$9,334.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,912.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,895.55
|
| Rate for Payer: Health EOS Commercial |
$8,941.59
|
| Rate for Payer: HFN Commercial |
$9,334.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,805.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,805.74
|
| Rate for Payer: Multiplan Commercial |
$7,860.74
|
| Rate for Payer: Preferred Network Access Commercial |
$9,334.62
|
| Rate for Payer: Quartz Beloit One Network |
$4,323.40
|
| Rate for Payer: Quartz Commercial |
$5,600.77
|
| Rate for Payer: The Alliance Commercial |
$4,912.96
|
| Rate for Payer: WEA Trust Commercial |
$5,404.26
|
| Rate for Payer: WPS Commercial |
$7,277.79
|
|
|
PET/CT Unlisted Whole Body
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2587065
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,504.86 |
| Max. Negotiated Rate |
$9,039.85 |
| Rate for Payer: Aetna Commercial |
$8,843.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,450.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,504.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,242.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,583.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,403.92
|
| Rate for Payer: Anthem Medicare Advantage |
$1,504.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,207.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,504.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,504.86
|
| 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 |
$9,039.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,504.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,498.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,504.86
|
| Rate for Payer: Health EOS Commercial |
$8,745.07
|
| Rate for Payer: HFN Commercial |
$9,039.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,598.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,504.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,504.86
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,504.86
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,504.86
|
| Rate for Payer: Multiplan Commercial |
$7,860.74
|
| Rate for Payer: NAPHCARE Commercial |
$2,257.29
|
| Rate for Payer: Preferred Network Access Commercial |
$9,039.85
|
| Rate for Payer: Quartz Beloit One Network |
$4,814.70
|
| Rate for Payer: Quartz Commercial |
$6,386.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,504.86
|
| Rate for Payer: The Alliance Commercial |
$6,019.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,504.86
|
| Rate for Payer: United Healthcare PPO |
$7,369.44
|
| Rate for Payer: WEA Trust Commercial |
$5,404.26
|
| Rate for Payer: Wellcare Medicare |
$1,504.86
|
| Rate for Payer: WPS Commercial |
$7,277.79
|
|
|
PET/CT Unlisted Whole Body
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2587065
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,814.70 |
| Max. Negotiated Rate |
$9,039.85 |
| Rate for Payer: Aetna Commercial |
$8,843.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,450.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,207.74
|
| Rate for Payer: Cash Price |
$2,834.40
|
| Rate for Payer: Cigna Commercial |
$9,039.85
|
| Rate for Payer: Health EOS Commercial |
$8,745.07
|
| Rate for Payer: HFN Commercial |
$9,039.85
|
| Rate for Payer: Multiplan Commercial |
$7,860.74
|
| Rate for Payer: Preferred Network Access Commercial |
$9,039.85
|
| Rate for Payer: Quartz Beloit One Network |
$4,814.70
|
| Rate for Payer: Quartz Commercial |
$5,895.55
|
| Rate for Payer: WEA Trust Commercial |
$5,404.26
|
| Rate for Payer: WPS Commercial |
$7,277.79
|
|
|
Petroleum gauze charge
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2844909
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Aetna Managed Medicare |
$7.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.71
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.06
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: NAPHCARE Commercial |
$16.85
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$18.25
|
| Rate for Payer: Quartz Medicare Advantage |
$16.85
|
| Rate for Payer: The Alliance Commercial |
$14.04
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
Petroleum gauze charge
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2844909
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$16.85
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
PET SCANS
|
Facility
|
OP
|
$300.91
|
|
|
Service Code
|
EAPG 00290
|
| Min. Negotiated Rate |
$289.34 |
| Max. Negotiated Rate |
$300.91 |
| Rate for Payer: Anthem Medicaid |
$289.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$289.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$289.34
|
| Rate for Payer: Dean Health Medicaid |
$289.34
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$289.34
|
| Rate for Payer: Managed Health Services Medicaid |
$300.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$289.34
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$289.34
|
| Rate for Payer: United Healthcare Medicaid |
$289.34
|
|
|
PGA Amp Target Nuclerc Acid
|
Professional
|
Both
|
$300.00
|
|
| Hospital Charge Code |
2778810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.28 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Aetna Commercial |
$296.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$268.32
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$296.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.20
|
| Rate for Payer: Health EOS Commercial |
$283.92
|
| Rate for Payer: HFN Commercial |
$296.40
|
| Rate for Payer: Multiplan Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$296.40
|
| Rate for Payer: Quartz Beloit One Network |
$137.28
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$156.00
|
| Rate for Payer: WEA Trust Commercial |
$171.60
|
| Rate for Payer: WPS Commercial |
$231.09
|
|
|
PGA Amp Target Nuclerc Acid
|
Facility
|
IP
|
$300.00
|
|
| Hospital Charge Code |
2778810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$152.88 |
| Max. Negotiated Rate |
$287.04 |
| Rate for Payer: Aetna Commercial |
$280.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$268.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.36
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$287.04
|
| Rate for Payer: Health EOS Commercial |
$277.68
|
| Rate for Payer: HFN Commercial |
$287.04
|
| Rate for Payer: Multiplan Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$287.04
|
| Rate for Payer: Quartz Beloit One Network |
$152.88
|
| Rate for Payer: Quartz Commercial |
$187.20
|
| Rate for Payer: WEA Trust Commercial |
$171.60
|
| Rate for Payer: WPS Commercial |
$231.09
|
|
|
PGA Amp Target Nuclerc Acid
|
Facility
|
OP
|
$300.00
|
|
| Hospital Charge Code |
2778810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$87.36 |
| Max. Negotiated Rate |
$287.04 |
| Rate for Payer: Aetna Commercial |
$280.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$268.32
|
| Rate for Payer: Aetna Managed Medicare |
$87.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$202.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$156.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$149.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.36
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$287.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.60
|
| Rate for Payer: Health EOS Commercial |
$277.68
|
| Rate for Payer: HFN Commercial |
$287.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$234.00
|
| Rate for Payer: Multiplan Commercial |
$249.60
|
| Rate for Payer: NAPHCARE Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$287.04
|
| Rate for Payer: Quartz Beloit One Network |
$152.88
|
| Rate for Payer: Quartz Commercial |
$202.80
|
| Rate for Payer: Quartz Medicare Advantage |
$187.20
|
| Rate for Payer: The Alliance Commercial |
$156.00
|
| Rate for Payer: United Healthcare PPO |
$234.00
|
| Rate for Payer: WEA Trust Commercial |
$171.60
|
| Rate for Payer: WPS Commercial |
$231.09
|
|
|
PGA Interp & Report
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
2778811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.09 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
PGA Interp & Report
|
Professional
|
Both
|
$114.00
|
|
| Hospital Charge Code |
2778811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$112.63 |
| Rate for Payer: Aetna Commercial |
$112.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$112.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.14
|
| Rate for Payer: Health EOS Commercial |
$107.89
|
| Rate for Payer: HFN Commercial |
$112.63
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$112.63
|
| Rate for Payer: Quartz Beloit One Network |
$52.17
|
| Rate for Payer: Quartz Commercial |
$67.58
|
| Rate for Payer: The Alliance Commercial |
$59.28
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
PGA Interp & Report
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
2778811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Aetna Managed Medicare |
$33.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.35
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.92
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: NAPHCARE Commercial |
$71.14
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$77.06
|
| Rate for Payer: Quartz Medicare Advantage |
$71.14
|
| Rate for Payer: The Alliance Commercial |
$59.28
|
| Rate for Payer: United Healthcare PPO |
$88.92
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
PGA Iso/Extract Nuclerc Acid
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2778812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$23.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.98
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.62
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$49.30
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: Quartz Medicare Advantage |
$49.30
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: United Healthcare PPO |
$61.62
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
PGA Iso/Extract Nuclerc Acid
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2778812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna Commercial |
$78.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$78.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.30
|
| Rate for Payer: Health EOS Commercial |
$74.77
|
| Rate for Payer: HFN Commercial |
$78.05
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$78.05
|
| Rate for Payer: Quartz Beloit One Network |
$36.15
|
| Rate for Payer: Quartz Commercial |
$46.83
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
PGA Iso/Extract Nuclerc Acid
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2778812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$49.30
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
PGA Mutat ID Enz Ligation
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2778813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Mutat ID Enz Ligation
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2778813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: United Healthcare PPO |
$222.30
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Mutat ID Enz Ligation
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2778813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$130.42 |
| Max. Negotiated Rate |
$281.58 |
| Rate for Payer: Aetna Commercial |
$281.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$281.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.84
|
| Rate for Payer: Health EOS Commercial |
$269.72
|
| Rate for Payer: HFN Commercial |
$281.58
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$281.58
|
| Rate for Payer: Quartz Beloit One Network |
$130.42
|
| Rate for Payer: Quartz Commercial |
$168.95
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Sep & ID High Res
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2778814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Sep & ID High Res
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2778814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: United Healthcare PPO |
$222.30
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PGA Sep & ID High Res
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2778814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$130.42 |
| Max. Negotiated Rate |
$281.58 |
| Rate for Payer: Aetna Commercial |
$281.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$281.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.84
|
| Rate for Payer: Health EOS Commercial |
$269.72
|
| Rate for Payer: HFN Commercial |
$281.58
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$281.58
|
| Rate for Payer: Quartz Beloit One Network |
$130.42
|
| Rate for Payer: Quartz Commercial |
$168.95
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
PHALANGECTOMY, TOE, EACH TOE
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 28150
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
PHARMACOTHERAPY BY EXTENDED INFUSION
|
Facility
|
OP
|
$110.57
|
|
|
Service Code
|
EAPG 00110
|
| Min. Negotiated Rate |
$106.32 |
| Max. Negotiated Rate |
$110.57 |
| Rate for Payer: Anthem Medicaid |
$106.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$106.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$106.32
|
| Rate for Payer: Dean Health Medicaid |
$106.32
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$106.32
|
| Rate for Payer: Managed Health Services Medicaid |
$110.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$106.32
|
| Rate for Payer: United Healthcare Medicaid |
$106.32
|
|
