|
PSA only, No Rfx
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
3457521
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.92 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$183.00
|
| Rate for Payer: Health EOS Commercial |
$277.55
|
| Rate for Payer: HFN Commercial |
$289.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.92
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: Preferred Network Access Commercial |
$289.75
|
| Rate for Payer: Quartz Beloit One Network |
$134.20
|
| Rate for Payer: Quartz Commercial |
$173.85
|
| Rate for Payer: The Alliance Commercial |
$152.50
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA only, No Rfx
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
3457521
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.45 |
| Max. Negotiated Rate |
$280.60 |
| Rate for Payer: Aetna Commercial |
$274.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.65
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$280.60
|
| Rate for Payer: Health EOS Commercial |
$271.45
|
| Rate for Payer: HFN Commercial |
$280.60
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: NAPHCARE Commercial |
$183.00
|
| Rate for Payer: Preferred Network Access Commercial |
$280.60
|
| Rate for Payer: Quartz Beloit One Network |
$149.45
|
| Rate for Payer: Quartz Commercial |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA, Quest Free
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
1124799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.92 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$183.00
|
| Rate for Payer: Health EOS Commercial |
$277.55
|
| Rate for Payer: HFN Commercial |
$289.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.92
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: Preferred Network Access Commercial |
$289.75
|
| Rate for Payer: Quartz Beloit One Network |
$134.20
|
| Rate for Payer: Quartz Commercial |
$173.85
|
| Rate for Payer: The Alliance Commercial |
$152.50
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA, Quest Free
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
1124799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.45 |
| Max. Negotiated Rate |
$280.60 |
| Rate for Payer: Aetna Commercial |
$274.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.65
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$280.60
|
| Rate for Payer: Health EOS Commercial |
$271.45
|
| Rate for Payer: HFN Commercial |
$280.60
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: NAPHCARE Commercial |
$183.00
|
| Rate for Payer: Preferred Network Access Commercial |
$280.60
|
| Rate for Payer: Quartz Beloit One Network |
$149.45
|
| Rate for Payer: Quartz Commercial |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA, Quest Free
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
1124799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$280.60 |
| Rate for Payer: Aetna Commercial |
$274.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Aetna Managed Medicare |
$18.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.53
|
| Rate for Payer: Anthem Medicaid |
$19.00
|
| Rate for Payer: Anthem Medicare Advantage |
$18.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.39
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$280.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.68
|
| Rate for Payer: Dean Health Medicaid |
$19.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.39
|
| Rate for Payer: Health EOS Commercial |
$271.45
|
| Rate for Payer: HFN Commercial |
$280.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.39
|
| Rate for Payer: Managed Health Services Medicaid |
$19.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.39
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.58
|
| Rate for Payer: Preferred Network Access Commercial |
$280.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.00
|
| Rate for Payer: Quartz Beloit One Network |
$149.45
|
| Rate for Payer: Quartz Commercial |
$198.25
|
| Rate for Payer: Quartz Medicare Advantage |
$18.39
|
| Rate for Payer: The Alliance Commercial |
$73.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.39
|
| Rate for Payer: United Healthcare PPO |
$228.75
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: Wellcare Medicare |
$18.39
|
| Rate for Payer: WMAP Medicaid |
$19.00
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA, Total to Quest w/ Reflex Free PSA
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
3249473
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$280.60 |
| Rate for Payer: Aetna Commercial |
$274.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Aetna Managed Medicare |
$18.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.53
|
| Rate for Payer: Anthem Medicaid |
$19.00
|
| Rate for Payer: Anthem Medicare Advantage |
$18.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.39
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$280.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.68
|
| Rate for Payer: Dean Health Medicaid |
$19.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.39
|
| Rate for Payer: Health EOS Commercial |
$271.45
|
| Rate for Payer: HFN Commercial |
$280.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.39
|
| Rate for Payer: Managed Health Services Medicaid |
$19.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.39
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.58
|
| Rate for Payer: Preferred Network Access Commercial |
$280.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.00
|
| Rate for Payer: Quartz Beloit One Network |
$149.45
|
| Rate for Payer: Quartz Commercial |
$198.25
|
| Rate for Payer: Quartz Medicare Advantage |
$18.39
|
| Rate for Payer: The Alliance Commercial |
$73.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.39
|
| Rate for Payer: United Healthcare PPO |
$228.75
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: Wellcare Medicare |
$18.39
|
| Rate for Payer: WMAP Medicaid |
$19.00
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA, Total to Quest w/ Reflex Free PSA
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
3249473
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.92 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$183.00
|
| Rate for Payer: Health EOS Commercial |
$277.55
|
| Rate for Payer: HFN Commercial |
$289.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.92
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: Preferred Network Access Commercial |
$289.75
|
| Rate for Payer: Quartz Beloit One Network |
$134.20
|
| Rate for Payer: Quartz Commercial |
$173.85
|
| Rate for Payer: The Alliance Commercial |
$152.50
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA, Total to Quest w/ Reflex Free PSA
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
3249473
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.45 |
| Max. Negotiated Rate |
$280.60 |
| Rate for Payer: Aetna Commercial |
$274.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.65
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$280.60
|
| Rate for Payer: Health EOS Commercial |
$271.45
|
| Rate for Payer: HFN Commercial |
$280.60
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: NAPHCARE Commercial |
$183.00
|
| Rate for Payer: Preferred Network Access Commercial |
$280.60
|
| Rate for Payer: Quartz Beloit One Network |
$149.45
|
| Rate for Payer: Quartz Commercial |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA w/ Rfx Free PSA
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
633810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$280.60 |
| Rate for Payer: Aetna Commercial |
$274.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Aetna Managed Medicare |
$18.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.53
|
| Rate for Payer: Anthem Medicaid |
$19.00
|
| Rate for Payer: Anthem Medicare Advantage |
$18.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.39
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$280.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.68
|
| Rate for Payer: Dean Health Medicaid |
$19.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.39
|
| Rate for Payer: Health EOS Commercial |
$271.45
|
| Rate for Payer: HFN Commercial |
$280.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.39
|
| Rate for Payer: Managed Health Services Medicaid |
$19.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.39
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.58
|
| Rate for Payer: Preferred Network Access Commercial |
$280.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.00
|
| Rate for Payer: Quartz Beloit One Network |
$149.45
|
| Rate for Payer: Quartz Commercial |
$198.25
|
| Rate for Payer: Quartz Medicare Advantage |
$18.39
|
| Rate for Payer: The Alliance Commercial |
$73.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.39
|
| Rate for Payer: United Healthcare PPO |
$228.75
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: Wellcare Medicare |
$18.39
|
| Rate for Payer: WMAP Medicaid |
$19.00
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA w/ Rfx Free PSA
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
633810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.45 |
| Max. Negotiated Rate |
$280.60 |
| Rate for Payer: Aetna Commercial |
$274.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.65
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$280.60
|
| Rate for Payer: Health EOS Commercial |
$271.45
|
| Rate for Payer: HFN Commercial |
$280.60
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: NAPHCARE Commercial |
$183.00
|
| Rate for Payer: Preferred Network Access Commercial |
$280.60
|
| Rate for Payer: Quartz Beloit One Network |
$149.45
|
| Rate for Payer: Quartz Commercial |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSA w/ Rfx Free PSA
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
633810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.92 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.30
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$183.00
|
| Rate for Payer: Health EOS Commercial |
$277.55
|
| Rate for Payer: HFN Commercial |
$289.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.92
|
| Rate for Payer: Multiplan Commercial |
$244.00
|
| Rate for Payer: Preferred Network Access Commercial |
$289.75
|
| Rate for Payer: Quartz Beloit One Network |
$134.20
|
| Rate for Payer: Quartz Commercial |
$173.85
|
| Rate for Payer: The Alliance Commercial |
$152.50
|
| Rate for Payer: WEA Trust Commercial |
$167.75
|
| Rate for Payer: WPS Commercial |
$225.91
|
|
|
PSMA. 18F-DCFPyL
|
Facility
|
OP
|
$1,021.00
|
|
|
Service Code
|
HCPCS A9595
|
| Hospital Charge Code |
6101629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$490.08 |
| Max. Negotiated Rate |
$2,321.41 |
| Rate for Payer: Aetna Commercial |
$918.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$878.06
|
| Rate for Payer: Aetna Managed Medicare |
$580.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$663.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$510.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$490.08
|
| Rate for Payer: Anthem Medicare Advantage |
$580.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$580.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$580.35
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cigna Commercial |
$939.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$580.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$571.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$580.35
|
| Rate for Payer: Health EOS Commercial |
$908.69
|
| Rate for Payer: HFN Commercial |
$939.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,158.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$580.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$580.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$580.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$580.35
|
| Rate for Payer: Multiplan Commercial |
$816.80
|
| Rate for Payer: NAPHCARE Commercial |
$870.53
|
| Rate for Payer: Preferred Network Access Commercial |
$939.32
|
| Rate for Payer: Quartz Beloit One Network |
$500.29
|
| Rate for Payer: Quartz Commercial |
$663.65
|
| Rate for Payer: Quartz Medicare Advantage |
$580.35
|
| Rate for Payer: The Alliance Commercial |
$2,321.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$580.35
|
| Rate for Payer: WEA Trust Commercial |
$561.55
|
| Rate for Payer: Wellcare Medicare |
$580.35
|
| Rate for Payer: WPS Commercial |
$756.25
|
|
|
PSMA. 18F-DCFPyL
|
Professional
|
Both
|
$1,021.00
|
|
|
Service Code
|
HCPCS A9595
|
| Hospital Charge Code |
6101629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$449.24 |
| Max. Negotiated Rate |
$969.95 |
| Rate for Payer: Aetna Commercial |
$969.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$878.06
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cigna Commercial |
$969.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$850.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$612.60
|
| Rate for Payer: Health EOS Commercial |
$929.11
|
| Rate for Payer: HFN Commercial |
$969.95
|
| Rate for Payer: Multiplan Commercial |
$816.80
|
| Rate for Payer: Preferred Network Access Commercial |
$969.95
|
| Rate for Payer: Quartz Beloit One Network |
$449.24
|
| Rate for Payer: Quartz Commercial |
$581.97
|
| Rate for Payer: The Alliance Commercial |
$510.50
|
| Rate for Payer: United Healthcare Medicaid |
$850.00
|
| Rate for Payer: WEA Trust Commercial |
$561.55
|
| Rate for Payer: WPS Commercial |
$756.25
|
|
|
PSMA. 18F-DCFPyL
|
Facility
|
IP
|
$1,021.00
|
|
|
Service Code
|
HCPCS A9595
|
| Hospital Charge Code |
6101629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$500.29 |
| Max. Negotiated Rate |
$939.32 |
| Rate for Payer: Aetna Commercial |
$918.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$878.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$541.13
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cigna Commercial |
$939.32
|
| Rate for Payer: Health EOS Commercial |
$908.69
|
| Rate for Payer: HFN Commercial |
$939.32
|
| Rate for Payer: Multiplan Commercial |
$816.80
|
| Rate for Payer: NAPHCARE Commercial |
$612.60
|
| Rate for Payer: Preferred Network Access Commercial |
$939.32
|
| Rate for Payer: Quartz Beloit One Network |
$500.29
|
| Rate for Payer: Quartz Commercial |
$612.60
|
| Rate for Payer: WEA Trust Commercial |
$561.55
|
| Rate for Payer: WPS Commercial |
$756.25
|
|
|
PSN FEMUR CR CMT CCR STD SZ 10 RT 42-5026-068-02
|
Facility
|
IP
|
$20,886.00
|
|
| Hospital Charge Code |
3901351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| Max. Negotiated Rate |
$19,215.12 |
| Rate for Payer: Aetna Commercial |
$18,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,961.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,069.58
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,215.12
|
| Rate for Payer: Health EOS Commercial |
$18,588.54
|
| Rate for Payer: HFN Commercial |
$19,215.12
|
| Rate for Payer: Multiplan Commercial |
$16,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,531.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,215.12
|
| Rate for Payer: Quartz Beloit One Network |
$10,234.14
|
| Rate for Payer: Quartz Commercial |
$12,531.60
|
| Rate for Payer: WEA Trust Commercial |
$11,487.30
|
| Rate for Payer: WPS Commercial |
$15,470.26
|
|
|
PSN FEMUR CR CMT CCR STD SZ 10 RT 42-5026-068-02
|
Facility
|
OP
|
$20,886.00
|
|
| Hospital Charge Code |
3901351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,848.08 |
| Max. Negotiated Rate |
$83,544.00 |
| Rate for Payer: Aetna Commercial |
$18,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,961.96
|
| Rate for Payer: Aetna Managed Medicare |
$5,848.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,575.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,443.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,025.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,069.58
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,215.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,687.81
|
| Rate for Payer: Health EOS Commercial |
$18,588.54
|
| Rate for Payer: HFN Commercial |
$19,215.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,664.50
|
| Rate for Payer: Multiplan Commercial |
$16,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,531.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,215.12
|
| Rate for Payer: Quartz Beloit One Network |
$10,234.14
|
| Rate for Payer: Quartz Commercial |
$13,575.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12,531.60
|
| Rate for Payer: The Alliance Commercial |
$83,544.00
|
| Rate for Payer: WEA Trust Commercial |
$11,487.30
|
| Rate for Payer: WPS Commercial |
$15,470.26
|
|
|
P.S.T. W/Allergenic Extracts, Immediate Reaction 95004
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 95004
|
| Hospital Charge Code |
1188807
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: United Healthcare Medicaid |
$2.17
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Psych and neuropsych test & scoring by physician; each add 30 min 96137
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
CPT 96137
|
| Hospital Charge Code |
5454801
|
| Min. Negotiated Rate |
$49.11 |
| Max. Negotiated Rate |
$163.40 |
| Rate for Payer: Aetna Commercial |
$163.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$163.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.20
|
| Rate for Payer: Health EOS Commercial |
$156.52
|
| Rate for Payer: HFN Commercial |
$163.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.35
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: Preferred Network Access Commercial |
$163.40
|
| Rate for Payer: Quartz Beloit One Network |
$75.68
|
| Rate for Payer: Quartz Commercial |
$98.04
|
| Rate for Payer: The Alliance Commercial |
$86.00
|
| Rate for Payer: United Healthcare Medicaid |
$49.11
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
Psych and neuropsych test & scoring by physician; first 30 min 96136
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 96136
|
| Hospital Charge Code |
5454802
|
| Min. Negotiated Rate |
$52.97 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna Commercial |
$176.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$176.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.60
|
| Rate for Payer: Health EOS Commercial |
$169.26
|
| Rate for Payer: HFN Commercial |
$176.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$81.97
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$176.70
|
| Rate for Payer: Quartz Beloit One Network |
$81.84
|
| Rate for Payer: Quartz Commercial |
$106.02
|
| Rate for Payer: The Alliance Commercial |
$93.00
|
| Rate for Payer: United Healthcare Medicaid |
$52.97
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Psych and neuropsych test & scoring by technician; each add 30 min 96139
|
Professional
|
Both
|
$154.00
|
|
|
Service Code
|
CPT 96139
|
| Hospital Charge Code |
5454803
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.58 |
| Max. Negotiated Rate |
$146.30 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$146.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.40
|
| Rate for Payer: Health EOS Commercial |
$140.14
|
| Rate for Payer: HFN Commercial |
$146.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.34
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: Preferred Network Access Commercial |
$146.30
|
| Rate for Payer: Quartz Beloit One Network |
$67.76
|
| Rate for Payer: Quartz Commercial |
$87.78
|
| Rate for Payer: The Alliance Commercial |
$77.00
|
| Rate for Payer: United Healthcare Medicaid |
$42.58
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
|
Psych and neuropsych test & scoring by technician; first 30 min 96138
|
Professional
|
Both
|
$154.00
|
|
|
Service Code
|
CPT 96138
|
| Hospital Charge Code |
5454804
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.58 |
| Max. Negotiated Rate |
$146.30 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$146.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.40
|
| Rate for Payer: Health EOS Commercial |
$140.14
|
| Rate for Payer: HFN Commercial |
$146.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.34
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: Preferred Network Access Commercial |
$146.30
|
| Rate for Payer: Quartz Beloit One Network |
$67.76
|
| Rate for Payer: Quartz Commercial |
$87.78
|
| Rate for Payer: The Alliance Commercial |
$77.00
|
| Rate for Payer: United Healthcare Medicaid |
$42.58
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
|
Psychiatric Diagnostic Eval/No Medical Services 90791
|
Professional
|
Both
|
$560.00
|
|
|
Service Code
|
CPT 90791
|
| Hospital Charge Code |
2990618
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$246.40 |
| Max. Negotiated Rate |
$536.10 |
| Rate for Payer: Aetna Commercial |
$532.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$481.60
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$532.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$280.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.00
|
| Rate for Payer: Health EOS Commercial |
$509.60
|
| Rate for Payer: HFN Commercial |
$532.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$536.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$536.10
|
| Rate for Payer: Multiplan Commercial |
$448.00
|
| Rate for Payer: Preferred Network Access Commercial |
$532.00
|
| Rate for Payer: Quartz Beloit One Network |
$246.40
|
| Rate for Payer: Quartz Commercial |
$319.20
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$308.00
|
| Rate for Payer: WPS Commercial |
$414.79
|
|
|
Psychological Testing Evaluation: each add hour 96131
|
Professional
|
Both
|
$328.00
|
|
|
Service Code
|
CPT 96131
|
| Hospital Charge Code |
5454798
|
| Min. Negotiated Rate |
$101.28 |
| Max. Negotiated Rate |
$311.60 |
| Rate for Payer: Aetna Commercial |
$311.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$282.08
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$311.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$101.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$196.80
|
| Rate for Payer: Health EOS Commercial |
$298.48
|
| Rate for Payer: HFN Commercial |
$311.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$278.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$278.34
|
| Rate for Payer: Multiplan Commercial |
$262.40
|
| Rate for Payer: Preferred Network Access Commercial |
$311.60
|
| Rate for Payer: Quartz Beloit One Network |
$144.32
|
| Rate for Payer: Quartz Commercial |
$186.96
|
| Rate for Payer: The Alliance Commercial |
$164.00
|
| Rate for Payer: United Healthcare Medicaid |
$101.28
|
| Rate for Payer: WEA Trust Commercial |
$180.40
|
| Rate for Payer: WPS Commercial |
$242.95
|
|
|
Psychological Testing Evaluation; first hour 96130
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
CPT 96130
|
| Hospital Charge Code |
5454797
|
| Min. Negotiated Rate |
$132.92 |
| Max. Negotiated Rate |
$399.00 |
| Rate for Payer: Aetna Commercial |
$399.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.20
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$399.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.00
|
| Rate for Payer: Health EOS Commercial |
$382.20
|
| Rate for Payer: HFN Commercial |
$399.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$370.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$370.37
|
| Rate for Payer: Multiplan Commercial |
$336.00
|
| Rate for Payer: Preferred Network Access Commercial |
$399.00
|
| Rate for Payer: Quartz Beloit One Network |
$184.80
|
| Rate for Payer: Quartz Commercial |
$239.40
|
| Rate for Payer: The Alliance Commercial |
$210.00
|
| Rate for Payer: United Healthcare Medicaid |
$132.92
|
| Rate for Payer: WEA Trust Commercial |
$231.00
|
| Rate for Payer: WPS Commercial |
$311.09
|
|
|
PSYCHOSES
|
Facility
|
IP
|
$36,647.00
|
|
|
Service Code
|
MSDRG 885
|
| Min. Negotiated Rate |
$13,182.55 |
| Max. Negotiated Rate |
$36,647.00 |
| Rate for Payer: Aetna Managed Medicare |
$13,182.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,742.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,030.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,930.86
|
| Rate for Payer: Anthem Medicare Advantage |
$13,182.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,182.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,182.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,182.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,235.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,182.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,644.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,182.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,182.55
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,182.55
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,182.55
|
| Rate for Payer: NAPHCARE Commercial |
$19,773.82
|
| Rate for Payer: Quartz Medicare Advantage |
$13,182.55
|
| Rate for Payer: The Alliance Commercial |
$36,647.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,182.55
|
| Rate for Payer: United Healthcare PPO |
$20,743.32
|
| Rate for Payer: Wellcare Medicare |
$13,182.55
|
|
