|
PET/CT Melanoma Initial Tx Whole Body
|
Facility
|
IP
|
$8,711.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
677603
|
| 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 Melanoma Initial Tx Whole Body
|
Professional
|
Both
|
$9,448.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2587054
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,157.12 |
| Max. Negotiated Rate |
$10,390.13 |
| 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 |
$10,390.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,390.13
|
| 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 Melanoma Initial Tx Whole Body
|
Facility
|
OP
|
$8,711.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
677603
|
| 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 Melanoma Sub Tx Whole Body
|
Facility
|
OP
|
$8,711.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2934811
|
| 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 Melanoma Sub Tx Whole Body
|
Facility
|
IP
|
$9,059.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2942844
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,438.91 |
| Max. Negotiated Rate |
$8,334.28 |
| Rate for Payer: Aetna Commercial |
$8,153.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,790.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,801.27
|
| Rate for Payer: Cash Price |
$2,717.70
|
| Rate for Payer: Cigna Commercial |
$8,334.28
|
| Rate for Payer: Health EOS Commercial |
$8,062.51
|
| Rate for Payer: HFN Commercial |
$8,334.28
|
| Rate for Payer: Multiplan Commercial |
$7,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,435.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,334.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,438.91
|
| Rate for Payer: Quartz Commercial |
$5,435.40
|
| Rate for Payer: WEA Trust Commercial |
$4,982.45
|
| Rate for Payer: WPS Commercial |
$6,710.00
|
|
|
PET/CT Melanoma Sub Tx Whole Body
|
Facility
|
IP
|
$8,711.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2934811
|
| 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 Melanoma Sub Tx Whole Body
|
Professional
|
Both
|
$9,059.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2942844
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$3,985.96 |
| Max. Negotiated Rate |
$10,390.13 |
| Rate for Payer: Aetna Commercial |
$8,606.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,790.74
|
| Rate for Payer: Cash Price |
$2,717.70
|
| Rate for Payer: Cash Price |
$2,717.70
|
| Rate for Payer: Cigna Commercial |
$8,606.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,529.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,435.40
|
| Rate for Payer: Health EOS Commercial |
$8,243.69
|
| Rate for Payer: HFN Commercial |
$8,606.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,390.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,390.13
|
| Rate for Payer: Multiplan Commercial |
$7,247.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,606.05
|
| Rate for Payer: Quartz Beloit One Network |
$3,985.96
|
| Rate for Payer: Quartz Commercial |
$5,163.63
|
| Rate for Payer: The Alliance Commercial |
$4,529.50
|
| Rate for Payer: WEA Trust Commercial |
$4,982.45
|
| Rate for Payer: WPS Commercial |
$6,710.00
|
|
|
PET/CT Melanoma Sub Tx Whole Body
|
Facility
|
OP
|
$9,059.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2942844
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,546.32 |
| Max. Negotiated Rate |
$8,334.28 |
| Rate for Payer: Aetna Commercial |
$8,153.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,790.74
|
| 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 |
$4,801.27
|
| 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 |
$2,717.70
|
| Rate for Payer: Cash Price |
$2,717.70
|
| Rate for Payer: Cash Price |
$2,717.70
|
| Rate for Payer: Cigna Commercial |
$8,334.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,069.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$8,062.51
|
| Rate for Payer: HFN Commercial |
$8,334.28
|
| 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 |
$7,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$8,334.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,438.91
|
| Rate for Payer: Quartz Commercial |
$5,888.35
|
| 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 |
$6,794.25
|
| Rate for Payer: WEA Trust Commercial |
$4,982.45
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$6,710.00
|
|
|
PET/CT Melanoma Sub Tx Whole Body
|
Professional
|
Both
|
$8,711.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2934811
|
| Min. Negotiated Rate |
$3,832.84 |
| Max. Negotiated Rate |
$10,390.13 |
| 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 |
$10,390.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,390.13
|
| 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 PSMA
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
6101640
|
|
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 PSMA
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
6101640
|
|
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 PSMA
|
Professional
|
Both
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
6101640
|
|
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 Pulmonary Solitary Nodule
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587059
|
|
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 Pulmonary Solitary Nodule
|
Professional
|
Both
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2584803
|
| 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 Pulmonary Solitary Nodule
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587059
|
|
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 Pulmonary Solitary Nodule
|
Professional
|
Both
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587059
|
|
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 Pulmonary Solitary Nodule
|
Facility
|
IP
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2584803
|
| 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 Pulmonary Solitary Nodule
|
Facility
|
OP
|
$8,711.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2584803
|
| 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 Sub Treatment Unlisted
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587062
|
|
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 Sub Treatment Unlisted
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
2587062
|
|
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 Unlisted Whole Body
|
Facility
|
OP
|
$9,448.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2587065
|
|
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 Unlisted Whole Body
|
Professional
|
Both
|
$9,448.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2587065
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$4,157.12 |
| Max. Negotiated Rate |
$10,390.13 |
| 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 |
$10,390.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,390.13
|
| 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 Unlisted Whole Body
|
Facility
|
IP
|
$9,448.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
2587065
|
|
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
|
|
|
Petroleum gauze charge
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2844909
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
Petroleum gauze charge
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2844909
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
