|
PROVOX LIFE SHOWER 8308
|
Facility
|
OP
|
$721.00
|
|
| Hospital Charge Code |
6175031
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.88 |
| Max. Negotiated Rate |
$2,884.00 |
| Rate for Payer: Aetna Commercial |
$648.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$620.06
|
| Rate for Payer: Aetna Managed Medicare |
$201.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$468.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$360.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$346.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$382.13
|
| Rate for Payer: Cash Price |
$216.30
|
| Rate for Payer: Cigna Commercial |
$663.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$403.47
|
| Rate for Payer: Health EOS Commercial |
$641.69
|
| Rate for Payer: HFN Commercial |
$663.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$540.75
|
| Rate for Payer: Multiplan Commercial |
$576.80
|
| Rate for Payer: NAPHCARE Commercial |
$432.60
|
| Rate for Payer: Preferred Network Access Commercial |
$663.32
|
| Rate for Payer: Quartz Beloit One Network |
$353.29
|
| Rate for Payer: Quartz Commercial |
$468.65
|
| Rate for Payer: Quartz Medicare Advantage |
$432.60
|
| Rate for Payer: The Alliance Commercial |
$2,884.00
|
| Rate for Payer: WEA Trust Commercial |
$396.55
|
| Rate for Payer: WPS Commercial |
$534.04
|
|
|
Prq Card Stent w/Angio 1 Vsl-Des
|
Facility
|
IP
|
$25,191.00
|
|
|
Service Code
|
HCPCS C9600
|
| Hospital Charge Code |
4964606
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$12,343.59 |
| Max. Negotiated Rate |
$23,175.72 |
| Rate for Payer: Aetna Commercial |
$22,671.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,664.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,351.23
|
| Rate for Payer: Cash Price |
$7,557.30
|
| Rate for Payer: Cigna Commercial |
$23,175.72
|
| Rate for Payer: Health EOS Commercial |
$22,419.99
|
| Rate for Payer: HFN Commercial |
$23,175.72
|
| Rate for Payer: Multiplan Commercial |
$20,152.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23,175.72
|
| Rate for Payer: Quartz Beloit One Network |
$12,343.59
|
| Rate for Payer: Quartz Commercial |
$15,114.60
|
| Rate for Payer: WEA Trust Commercial |
$13,855.05
|
| Rate for Payer: WPS Commercial |
$18,658.97
|
|
|
Prq Card Stent w/Angio 1 Vsl-Des
|
Facility
|
OP
|
$25,191.00
|
|
|
Service Code
|
HCPCS C9600
|
| Hospital Charge Code |
4964606
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$10,873.62 |
| Max. Negotiated Rate |
$43,494.48 |
| Rate for Payer: Aetna Commercial |
$22,671.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,664.26
|
| Rate for Payer: Aetna Managed Medicare |
$10,873.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,311.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,676.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,643.00
|
| Rate for Payer: Anthem Medicare Advantage |
$10,873.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,351.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,873.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,873.62
|
| Rate for Payer: Cash Price |
$7,557.30
|
| Rate for Payer: Cash Price |
$7,557.30
|
| Rate for Payer: Cash Price |
$7,557.30
|
| Rate for Payer: Cigna Commercial |
$23,175.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,873.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,873.62
|
| Rate for Payer: Health EOS Commercial |
$22,419.99
|
| Rate for Payer: HFN Commercial |
$23,175.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,449.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,873.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,873.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,873.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,873.62
|
| Rate for Payer: Multiplan Commercial |
$20,152.80
|
| Rate for Payer: NAPHCARE Commercial |
$16,310.43
|
| Rate for Payer: Preferred Network Access Commercial |
$23,175.72
|
| Rate for Payer: Quartz Beloit One Network |
$12,343.59
|
| Rate for Payer: Quartz Commercial |
$16,374.15
|
| Rate for Payer: Quartz Medicare Advantage |
$10,873.62
|
| Rate for Payer: The Alliance Commercial |
$43,494.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,873.62
|
| Rate for Payer: United Healthcare PPO |
$18,893.25
|
| Rate for Payer: WEA Trust Commercial |
$13,855.05
|
| Rate for Payer: Wellcare Medicare |
$10,873.62
|
| Rate for Payer: WPS Commercial |
$18,658.97
|
|
|
.PSA Free, Quest
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
3301541
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$64.92 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.20
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: HFN Commercial |
$63.65
|
| 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 |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: The Alliance Commercial |
$33.50
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
.PSA Free, Quest
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
3301541
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$73.56 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| 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 |
$35.51
|
| 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 |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| 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 |
$37.49
|
| 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 |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| 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 |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$27.58
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.00
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$43.55
|
| 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 |
$50.25
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: Wellcare Medicare |
$18.39
|
| Rate for Payer: WMAP Medicaid |
$19.00
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
.PSA Free, Quest
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
3301541
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$61.64 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$40.20
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$40.20
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
PSA only, No Rfx
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
3457521
|
|
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 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 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, 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
|
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, 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, 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
|
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
|
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
|
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
|
|
|
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
|
|
|
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
|
|
|
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
|
|
|
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: 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
|
|
