|
Phototherapy Triple - Daily Charges
|
Facility
|
IP
|
$904.00
|
|
| Hospital Charge Code |
3003957
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$460.68 |
| Max. Negotiated Rate |
$864.95 |
| Rate for Payer: Aetna Commercial |
$846.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.28
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$864.95
|
| Rate for Payer: Health EOS Commercial |
$836.74
|
| Rate for Payer: HFN Commercial |
$864.95
|
| Rate for Payer: Multiplan Commercial |
$752.13
|
| Rate for Payer: Preferred Network Access Commercial |
$864.95
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$564.10
|
| Rate for Payer: WEA Trust Commercial |
$517.09
|
| Rate for Payer: WPS Commercial |
$696.35
|
|
|
Phototherapy Triple - Daily Charges
|
Facility
|
OP
|
$904.00
|
|
| Hospital Charge Code |
3003957
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$263.24 |
| Max. Negotiated Rate |
$864.95 |
| Rate for Payer: Aetna Commercial |
$846.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.54
|
| Rate for Payer: Aetna Managed Medicare |
$263.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.28
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$864.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.13
|
| Rate for Payer: Health EOS Commercial |
$836.74
|
| Rate for Payer: HFN Commercial |
$864.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.12
|
| Rate for Payer: Multiplan Commercial |
$752.13
|
| Rate for Payer: NAPHCARE Commercial |
$564.10
|
| Rate for Payer: Preferred Network Access Commercial |
$864.95
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$611.10
|
| Rate for Payer: Quartz Medicare Advantage |
$564.10
|
| Rate for Payer: The Alliance Commercial |
$470.08
|
| Rate for Payer: WEA Trust Commercial |
$517.09
|
| Rate for Payer: WPS Commercial |
$696.35
|
|
|
Phototherapy Triple - Nursery Daily Charges
|
Facility
|
IP
|
$904.00
|
|
| Hospital Charge Code |
3003949
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$460.68 |
| Max. Negotiated Rate |
$864.95 |
| Rate for Payer: Aetna Commercial |
$846.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.28
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$864.95
|
| Rate for Payer: Health EOS Commercial |
$836.74
|
| Rate for Payer: HFN Commercial |
$864.95
|
| Rate for Payer: Multiplan Commercial |
$752.13
|
| Rate for Payer: Preferred Network Access Commercial |
$864.95
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$564.10
|
| Rate for Payer: WEA Trust Commercial |
$517.09
|
| Rate for Payer: WPS Commercial |
$696.35
|
|
|
Phototherapy Triple - Nursery Daily Charges
|
Facility
|
OP
|
$904.00
|
|
| Hospital Charge Code |
3003949
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$263.24 |
| Max. Negotiated Rate |
$864.95 |
| Rate for Payer: Aetna Commercial |
$846.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.54
|
| Rate for Payer: Aetna Managed Medicare |
$263.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.28
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$864.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.13
|
| Rate for Payer: Health EOS Commercial |
$836.74
|
| Rate for Payer: HFN Commercial |
$864.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.12
|
| Rate for Payer: Multiplan Commercial |
$752.13
|
| Rate for Payer: NAPHCARE Commercial |
$564.10
|
| Rate for Payer: Preferred Network Access Commercial |
$864.95
|
| Rate for Payer: Quartz Beloit One Network |
$460.68
|
| Rate for Payer: Quartz Commercial |
$611.10
|
| Rate for Payer: Quartz Medicare Advantage |
$564.10
|
| Rate for Payer: The Alliance Commercial |
$470.08
|
| Rate for Payer: WEA Trust Commercial |
$517.09
|
| Rate for Payer: WPS Commercial |
$696.35
|
|
|
PHOTOVAPORIZATION PROSTATE/BLADDER
|
Facility
|
OP
|
$12,167.00
|
|
|
Service Code
|
CPT 52648
|
| Hospital Charge Code |
2960194
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$22,570.79 |
| Rate for Payer: Aetna Commercial |
$11,388.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,882.16
|
| Rate for Payer: Aetna Managed Medicare |
$5,642.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$5,642.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,706.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,642.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,642.70
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cigna Commercial |
$11,641.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,642.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,642.70
|
| Rate for Payer: Health EOS Commercial |
$11,261.78
|
| Rate for Payer: HFN Commercial |
$11,641.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,990.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,642.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,642.70
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,642.70
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,642.70
|
| Rate for Payer: Multiplan Commercial |
$10,122.94
|
| Rate for Payer: NAPHCARE Commercial |
$8,464.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,641.39
|
| Rate for Payer: Quartz Beloit One Network |
$6,200.30
|
| Rate for Payer: Quartz Commercial |
$8,224.89
|
| Rate for Payer: Quartz Medicare Advantage |
$5,642.70
|
| Rate for Payer: The Alliance Commercial |
$22,570.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,642.70
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: WEA Trust Commercial |
$6,959.52
|
| Rate for Payer: Wellcare Medicare |
$5,642.70
|
| Rate for Payer: WPS Commercial |
$9,372.24
|
|
|
PHOTOVAPORIZATION PROSTATE/BLADDER
|
Facility
|
IP
|
$12,167.00
|
|
|
Service Code
|
CPT 52648
|
| Hospital Charge Code |
2960194
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,200.30 |
| Max. Negotiated Rate |
$11,641.39 |
| Rate for Payer: Aetna Commercial |
$11,388.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,882.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,706.45
|
| Rate for Payer: Cash Price |
$3,650.10
|
| Rate for Payer: Cigna Commercial |
$11,641.39
|
| Rate for Payer: Health EOS Commercial |
$11,261.78
|
| Rate for Payer: HFN Commercial |
$11,641.39
|
| Rate for Payer: Multiplan Commercial |
$10,122.94
|
| Rate for Payer: Preferred Network Access Commercial |
$11,641.39
|
| Rate for Payer: Quartz Beloit One Network |
$6,200.30
|
| Rate for Payer: Quartz Commercial |
$7,592.21
|
| Rate for Payer: WEA Trust Commercial |
$6,959.52
|
| Rate for Payer: WPS Commercial |
$9,372.24
|
|
|
pH, Pleural Fluid
|
Professional
|
Both
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$57.30 |
| Rate for Payer: Aetna Commercial |
$57.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$57.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$54.89
|
| Rate for Payer: HFN Commercial |
$57.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$57.30
|
| Rate for Payer: Quartz Beloit One Network |
$26.54
|
| Rate for Payer: Quartz Commercial |
$34.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$16.38
|
|
|
pH, Pleural Fluid
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$36.19
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
pH, Pleural Fluid
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5455093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.18
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$39.21
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: United Healthcare PPO |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: Wellcare Medicare |
$3.72
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
pH, Urine
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
pH, Urine
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.38
|
|
|
pH, Urine
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
5474694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.18
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: United Healthcare PPO |
$17.16
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: Wellcare Medicare |
$3.72
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
pH, Venous
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$374.56 |
| Max. Negotiated Rate |
$703.25 |
| Rate for Payer: Aetna Commercial |
$687.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.13
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$703.25
|
| Rate for Payer: Health EOS Commercial |
$680.32
|
| Rate for Payer: HFN Commercial |
$703.25
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: Preferred Network Access Commercial |
$703.25
|
| Rate for Payer: Quartz Beloit One Network |
$374.56
|
| Rate for Payer: Quartz Commercial |
$458.64
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: WPS Commercial |
$566.17
|
|
|
pH, Venous
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$726.18 |
| Rate for Payer: Aetna Commercial |
$726.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Aetna Managed Medicare |
$11.44
|
| Rate for Payer: Anthem Medicare Advantage |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.44
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$726.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$382.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.44
|
| Rate for Payer: Health EOS Commercial |
$695.60
|
| Rate for Payer: HFN Commercial |
$726.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.44
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: NAPHCARE Commercial |
$17.16
|
| Rate for Payer: Preferred Network Access Commercial |
$726.18
|
| Rate for Payer: Quartz Beloit One Network |
$336.34
|
| Rate for Payer: Quartz Commercial |
$435.71
|
| Rate for Payer: Quartz Medicare Advantage |
$11.44
|
| Rate for Payer: The Alliance Commercial |
$45.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: WPS Commercial |
$50.34
|
|
|
pH, Venous
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
633795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$703.25 |
| Rate for Payer: Aetna Commercial |
$687.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Aetna Managed Medicare |
$11.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.99
|
| Rate for Payer: Anthem Medicare Advantage |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.44
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$703.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$427.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.44
|
| Rate for Payer: Health EOS Commercial |
$680.32
|
| Rate for Payer: HFN Commercial |
$703.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.44
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: NAPHCARE Commercial |
$17.16
|
| Rate for Payer: Preferred Network Access Commercial |
$703.25
|
| Rate for Payer: Quartz Beloit One Network |
$374.56
|
| Rate for Payer: Quartz Commercial |
$496.86
|
| Rate for Payer: Quartz Medicare Advantage |
$11.44
|
| Rate for Payer: The Alliance Commercial |
$45.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.44
|
| Rate for Payer: United Healthcare PPO |
$573.30
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: Wellcare Medicare |
$11.44
|
| Rate for Payer: WPS Commercial |
$566.17
|
|
|
Physical Performance Test Charges
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
CPT 97750 GP
|
| Hospital Charge Code |
2472554
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Physical Performance Test Charges
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
CPT 97750 GP
|
| Hospital Charge Code |
2472554
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: United Healthcare PPO |
$250.38
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Physical Perf Test - FCA Charges
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
3007746
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$40.48 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$40.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$86.74
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$86.74
|
| Rate for Payer: The Alliance Commercial |
$72.28
|
| Rate for Payer: United Healthcare PPO |
$108.42
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Physical Perf Test - FCA Charges
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
3007746
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Physical Perf Test - Missed FCA Charges
|
Facility
|
OP
|
$587.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
3007750
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$170.93 |
| Max. Negotiated Rate |
$561.64 |
| Rate for Payer: Aetna Commercial |
$549.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.01
|
| Rate for Payer: Aetna Managed Medicare |
$170.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.55
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$561.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.63
|
| Rate for Payer: Health EOS Commercial |
$543.33
|
| Rate for Payer: HFN Commercial |
$561.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$488.38
|
| Rate for Payer: NAPHCARE Commercial |
$366.29
|
| Rate for Payer: Preferred Network Access Commercial |
$561.64
|
| Rate for Payer: Quartz Beloit One Network |
$299.14
|
| Rate for Payer: Quartz Commercial |
$396.81
|
| Rate for Payer: Quartz Medicare Advantage |
$366.29
|
| Rate for Payer: The Alliance Commercial |
$305.24
|
| Rate for Payer: United Healthcare PPO |
$457.86
|
| Rate for Payer: WEA Trust Commercial |
$335.76
|
| Rate for Payer: WPS Commercial |
$452.17
|
|
|
Physical Perf Test - Missed FCA Charges
|
Facility
|
IP
|
$587.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
3007750
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$299.14 |
| Max. Negotiated Rate |
$561.64 |
| Rate for Payer: Aetna Commercial |
$549.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.55
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$561.64
|
| Rate for Payer: Health EOS Commercial |
$543.33
|
| Rate for Payer: HFN Commercial |
$561.64
|
| Rate for Payer: Multiplan Commercial |
$488.38
|
| Rate for Payer: Preferred Network Access Commercial |
$561.64
|
| Rate for Payer: Quartz Beloit One Network |
$299.14
|
| Rate for Payer: Quartz Commercial |
$366.29
|
| Rate for Payer: WEA Trust Commercial |
$335.76
|
| Rate for Payer: WPS Commercial |
$452.17
|
|
|
Physical Perf Test - Modified FCA Charges
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
3007748
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.47 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$47.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.87
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$101.71
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$101.71
|
| Rate for Payer: The Alliance Commercial |
$84.76
|
| Rate for Payer: United Healthcare PPO |
$127.14
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
Physical Perf Test - Modified FCA Charges
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
3007748
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
Physical Perf Test WH Eval Charges
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
2564919
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$57.37 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Aetna Managed Medicare |
$57.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.65
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: NAPHCARE Commercial |
$122.93
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$133.17
|
| Rate for Payer: Quartz Medicare Advantage |
$122.93
|
| Rate for Payer: The Alliance Commercial |
$102.44
|
| Rate for Payer: United Healthcare PPO |
$153.66
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
Physical Perf Test WH Eval Charges
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
CPT 97750 GO
|
| Hospital Charge Code |
2564919
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$100.39 |
| Max. Negotiated Rate |
$188.49 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$122.93
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
