|
PMIC/ID109
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313515
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$8.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.36
|
| Rate for Payer: Anthem Medicaid |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.65
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.68
|
| Rate for Payer: Dean Health Medicaid |
$8.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.65
|
| Rate for Payer: Managed Health Services Medicaid |
$9.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.65
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.98
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.94
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$127.40
|
| Rate for Payer: Quartz Medicare Advantage |
$8.65
|
| Rate for Payer: The Alliance Commercial |
$34.60
|
| Rate for Payer: United Healthcare Medicaid |
$8.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.65
|
| Rate for Payer: United Healthcare PPO |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: Wellcare Medicare |
$8.65
|
| Rate for Payer: WMAP Medicaid |
$8.94
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
PMIC/ID109
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313515
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.04 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
PMP22 DNA Sequencing
|
Facility
|
IP
|
$3,172.00
|
|
|
Service Code
|
CPT 81325
|
| Hospital Charge Code |
5273723
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,554.28 |
| Max. Negotiated Rate |
$2,918.24 |
| Rate for Payer: Aetna Commercial |
$2,854.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,681.16
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cigna Commercial |
$2,918.24
|
| Rate for Payer: Health EOS Commercial |
$2,823.08
|
| Rate for Payer: HFN Commercial |
$2,918.24
|
| Rate for Payer: Multiplan Commercial |
$2,537.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,918.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,554.28
|
| Rate for Payer: Quartz Commercial |
$1,903.20
|
| Rate for Payer: WEA Trust Commercial |
$1,744.60
|
| Rate for Payer: WPS Commercial |
$2,349.50
|
|
|
PMP22 DNA Sequencing
|
Facility
|
OP
|
$3,172.00
|
|
|
Service Code
|
CPT 81325
|
| Hospital Charge Code |
5273723
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$267.52 |
| Max. Negotiated Rate |
$3,078.32 |
| Rate for Payer: Aetna Commercial |
$2,854.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.92
|
| Rate for Payer: Aetna Managed Medicare |
$769.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,885.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,346.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,277.50
|
| Rate for Payer: Anthem Medicaid |
$267.52
|
| Rate for Payer: Anthem Medicare Advantage |
$769.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,681.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$769.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$769.58
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cigna Commercial |
$2,918.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$769.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$267.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,775.05
|
| Rate for Payer: Dean Health Medicaid |
$267.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$769.58
|
| Rate for Payer: Health EOS Commercial |
$2,823.08
|
| Rate for Payer: HFN Commercial |
$2,918.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,862.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$769.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$267.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$769.58
|
| Rate for Payer: Managed Health Services Medicaid |
$278.22
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$769.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$769.58
|
| Rate for Payer: Multiplan Commercial |
$2,537.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,154.37
|
| Rate for Payer: Preferred Network Access Commercial |
$2,918.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$267.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,554.28
|
| Rate for Payer: Quartz Commercial |
$2,061.80
|
| Rate for Payer: Quartz Medicare Advantage |
$769.58
|
| Rate for Payer: The Alliance Commercial |
$3,078.32
|
| Rate for Payer: United Healthcare Medicaid |
$267.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$769.58
|
| Rate for Payer: United Healthcare PPO |
$2,379.00
|
| Rate for Payer: WEA Trust Commercial |
$1,744.60
|
| Rate for Payer: Wellcare Medicare |
$769.58
|
| Rate for Payer: WMAP Medicaid |
$267.52
|
| Rate for Payer: WPS Commercial |
$2,349.50
|
|
|
PMP22 DNA Sequencing
|
Professional
|
Both
|
$3,172.00
|
|
|
Service Code
|
CPT 81325
|
| Hospital Charge Code |
5273723
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,395.68 |
| Max. Negotiated Rate |
$3,013.40 |
| Rate for Payer: Aetna Commercial |
$3,013.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.92
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cigna Commercial |
$3,013.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,586.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,903.20
|
| Rate for Payer: Health EOS Commercial |
$2,886.52
|
| Rate for Payer: HFN Commercial |
$3,013.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,716.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,716.62
|
| Rate for Payer: Multiplan Commercial |
$2,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,013.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,395.68
|
| Rate for Payer: Quartz Commercial |
$1,808.04
|
| Rate for Payer: The Alliance Commercial |
$1,586.00
|
| Rate for Payer: WEA Trust Commercial |
$1,744.60
|
| Rate for Payer: WPS Commercial |
$2,349.50
|
|
|
PMS2
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 81317
|
| Hospital Charge Code |
5542927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$327.32 |
| Max. Negotiated Rate |
$2,706.00 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Aetna Managed Medicare |
$676.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,536.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,183.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,122.99
|
| Rate for Payer: Anthem Medicaid |
$625.03
|
| Rate for Payer: Anthem Medicare Advantage |
$676.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$676.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$676.50
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$676.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$625.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.81
|
| Rate for Payer: Dean Health Medicaid |
$625.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$676.50
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,516.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$676.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$625.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$676.50
|
| Rate for Payer: Managed Health Services Medicaid |
$650.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$676.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$676.50
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,014.75
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$625.03
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$434.20
|
| Rate for Payer: Quartz Medicare Advantage |
$676.50
|
| Rate for Payer: The Alliance Commercial |
$2,706.00
|
| Rate for Payer: United Healthcare Medicaid |
$625.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$676.50
|
| Rate for Payer: United Healthcare PPO |
$501.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: Wellcare Medicare |
$676.50
|
| Rate for Payer: WMAP Medicaid |
$625.03
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
PMS2
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 81317
|
| Hospital Charge Code |
5542927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$327.32 |
| Max. Negotiated Rate |
$614.56 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$400.80
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$400.80
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
PMS2
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
CPT 81317
|
| Hospital Charge Code |
5542927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$293.92 |
| Max. Negotiated Rate |
$2,388.05 |
| Rate for Payer: Aetna Commercial |
$634.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$634.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$334.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$400.80
|
| Rate for Payer: Health EOS Commercial |
$607.88
|
| Rate for Payer: HFN Commercial |
$634.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,388.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,388.05
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: Preferred Network Access Commercial |
$634.60
|
| Rate for Payer: Quartz Beloit One Network |
$293.92
|
| Rate for Payer: Quartz Commercial |
$380.76
|
| Rate for Payer: The Alliance Commercial |
$334.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
PMS2 Dup/Del
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 81319
|
| Hospital Charge Code |
5542928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$327.32 |
| Max. Negotiated Rate |
$614.56 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$400.80
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$400.80
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
PMS2 Dup/Del
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 81319
|
| Hospital Charge Code |
5542928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$177.33 |
| Max. Negotiated Rate |
$814.00 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Aetna Managed Medicare |
$203.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$763.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$356.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$337.81
|
| Rate for Payer: Anthem Medicaid |
$177.33
|
| Rate for Payer: Anthem Medicare Advantage |
$203.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$203.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$203.50
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$203.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$177.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.81
|
| Rate for Payer: Dean Health Medicaid |
$177.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$203.50
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$757.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$203.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$177.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$203.50
|
| Rate for Payer: Managed Health Services Medicaid |
$184.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$203.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$203.50
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$305.25
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$177.33
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$434.20
|
| Rate for Payer: Quartz Medicare Advantage |
$203.50
|
| Rate for Payer: The Alliance Commercial |
$814.00
|
| Rate for Payer: United Healthcare Medicaid |
$177.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$203.50
|
| Rate for Payer: United Healthcare PPO |
$501.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: Wellcare Medicare |
$203.50
|
| Rate for Payer: WMAP Medicaid |
$177.33
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
PMS2 Dup/Del
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
CPT 81319
|
| Hospital Charge Code |
5542928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$293.92 |
| Max. Negotiated Rate |
$718.36 |
| Rate for Payer: Aetna Commercial |
$634.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$634.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$334.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$400.80
|
| Rate for Payer: Health EOS Commercial |
$607.88
|
| Rate for Payer: HFN Commercial |
$634.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$718.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$718.36
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: Preferred Network Access Commercial |
$634.60
|
| Rate for Payer: Quartz Beloit One Network |
$293.92
|
| Rate for Payer: Quartz Commercial |
$380.76
|
| Rate for Payer: The Alliance Commercial |
$334.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
PNEUMATIC WALKER (L) 01F-L
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
2972438
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.20 |
| Max. Negotiated Rate |
$3,760.00 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Aetna Managed Medicare |
$263.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.02
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.00
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$611.00
|
| Rate for Payer: Quartz Medicare Advantage |
$564.00
|
| Rate for Payer: The Alliance Commercial |
$3,760.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
PNEUMATIC WALKER (L) 01F-L
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
2972438
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$864.80 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
PNEUMATIC WALKER (M) 01F-M
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
2972437
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$864.80 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
PNEUMATIC WALKER (M) 01F-M
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
2972437
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.20 |
| Max. Negotiated Rate |
$3,760.00 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Aetna Managed Medicare |
$263.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.02
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.00
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$611.00
|
| Rate for Payer: Quartz Medicare Advantage |
$564.00
|
| Rate for Payer: The Alliance Commercial |
$3,760.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
PNEUMATIC WALKER (S) 01F-S
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
2972821
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$864.80 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
PNEUMATIC WALKER (S) 01F-S
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
2972821
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.20 |
| Max. Negotiated Rate |
$3,760.00 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Aetna Managed Medicare |
$263.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.02
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.00
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$611.00
|
| Rate for Payer: Quartz Medicare Advantage |
$564.00
|
| Rate for Payer: The Alliance Commercial |
$3,760.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
PNEUMATIC WALK(L) SHORT 01A-L
|
Facility
|
IP
|
$872.00
|
|
| Hospital Charge Code |
2972440
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$427.28 |
| Max. Negotiated Rate |
$802.24 |
| Rate for Payer: Aetna Commercial |
$784.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$462.16
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$802.24
|
| Rate for Payer: Health EOS Commercial |
$776.08
|
| Rate for Payer: HFN Commercial |
$802.24
|
| Rate for Payer: Multiplan Commercial |
$697.60
|
| Rate for Payer: NAPHCARE Commercial |
$523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$802.24
|
| Rate for Payer: Quartz Beloit One Network |
$427.28
|
| Rate for Payer: Quartz Commercial |
$523.20
|
| Rate for Payer: WEA Trust Commercial |
$479.60
|
| Rate for Payer: WPS Commercial |
$645.89
|
|
|
PNEUMATIC WALK(L) SHORT 01A-L
|
Facility
|
OP
|
$872.00
|
|
| Hospital Charge Code |
2972440
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$244.16 |
| Max. Negotiated Rate |
$3,488.00 |
| Rate for Payer: Aetna Commercial |
$784.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.92
|
| Rate for Payer: Aetna Managed Medicare |
$244.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$566.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$436.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$418.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$462.16
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$802.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$487.97
|
| Rate for Payer: Health EOS Commercial |
$776.08
|
| Rate for Payer: HFN Commercial |
$802.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$654.00
|
| Rate for Payer: Multiplan Commercial |
$697.60
|
| Rate for Payer: NAPHCARE Commercial |
$523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$802.24
|
| Rate for Payer: Quartz Beloit One Network |
$427.28
|
| Rate for Payer: Quartz Commercial |
$566.80
|
| Rate for Payer: Quartz Medicare Advantage |
$523.20
|
| Rate for Payer: The Alliance Commercial |
$3,488.00
|
| Rate for Payer: WEA Trust Commercial |
$479.60
|
| Rate for Payer: WPS Commercial |
$645.89
|
|
|
PNEUMATIC WALK(M) SHORT 01-AM
|
Facility
|
OP
|
$872.00
|
|
| Hospital Charge Code |
2972439
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$244.16 |
| Max. Negotiated Rate |
$3,488.00 |
| Rate for Payer: Aetna Commercial |
$784.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.92
|
| Rate for Payer: Aetna Managed Medicare |
$244.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$566.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$436.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$418.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$462.16
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$802.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$487.97
|
| Rate for Payer: Health EOS Commercial |
$776.08
|
| Rate for Payer: HFN Commercial |
$802.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$654.00
|
| Rate for Payer: Multiplan Commercial |
$697.60
|
| Rate for Payer: NAPHCARE Commercial |
$523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$802.24
|
| Rate for Payer: Quartz Beloit One Network |
$427.28
|
| Rate for Payer: Quartz Commercial |
$566.80
|
| Rate for Payer: Quartz Medicare Advantage |
$523.20
|
| Rate for Payer: The Alliance Commercial |
$3,488.00
|
| Rate for Payer: WEA Trust Commercial |
$479.60
|
| Rate for Payer: WPS Commercial |
$645.89
|
|
|
PNEUMATIC WALK(M) SHORT 01-AM
|
Facility
|
IP
|
$872.00
|
|
| Hospital Charge Code |
2972439
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$427.28 |
| Max. Negotiated Rate |
$802.24 |
| Rate for Payer: Aetna Commercial |
$784.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$462.16
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$802.24
|
| Rate for Payer: Health EOS Commercial |
$776.08
|
| Rate for Payer: HFN Commercial |
$802.24
|
| Rate for Payer: Multiplan Commercial |
$697.60
|
| Rate for Payer: NAPHCARE Commercial |
$523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$802.24
|
| Rate for Payer: Quartz Beloit One Network |
$427.28
|
| Rate for Payer: Quartz Commercial |
$523.20
|
| Rate for Payer: WEA Trust Commercial |
$479.60
|
| Rate for Payer: WPS Commercial |
$645.89
|
|
|
PNEUMATIC WALK(S) SHORT 01A-S
|
Facility
|
IP
|
$872.00
|
|
| Hospital Charge Code |
2972377
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$427.28 |
| Max. Negotiated Rate |
$802.24 |
| Rate for Payer: Aetna Commercial |
$784.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$462.16
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$802.24
|
| Rate for Payer: Health EOS Commercial |
$776.08
|
| Rate for Payer: HFN Commercial |
$802.24
|
| Rate for Payer: Multiplan Commercial |
$697.60
|
| Rate for Payer: NAPHCARE Commercial |
$523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$802.24
|
| Rate for Payer: Quartz Beloit One Network |
$427.28
|
| Rate for Payer: Quartz Commercial |
$523.20
|
| Rate for Payer: WEA Trust Commercial |
$479.60
|
| Rate for Payer: WPS Commercial |
$645.89
|
|
|
PNEUMATIC WALK(S) SHORT 01A-S
|
Facility
|
OP
|
$872.00
|
|
| Hospital Charge Code |
2972377
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$244.16 |
| Max. Negotiated Rate |
$3,488.00 |
| Rate for Payer: Aetna Commercial |
$784.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.92
|
| Rate for Payer: Aetna Managed Medicare |
$244.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$566.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$436.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$418.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$462.16
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$802.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$487.97
|
| Rate for Payer: Health EOS Commercial |
$776.08
|
| Rate for Payer: HFN Commercial |
$802.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$654.00
|
| Rate for Payer: Multiplan Commercial |
$697.60
|
| Rate for Payer: NAPHCARE Commercial |
$523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$802.24
|
| Rate for Payer: Quartz Beloit One Network |
$427.28
|
| Rate for Payer: Quartz Commercial |
$566.80
|
| Rate for Payer: Quartz Medicare Advantage |
$523.20
|
| Rate for Payer: The Alliance Commercial |
$3,488.00
|
| Rate for Payer: WEA Trust Commercial |
$479.60
|
| Rate for Payer: WPS Commercial |
$645.89
|
|
|
Pneuma/vac walk boot pre ots L4361
|
Facility
|
OP
|
$790.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
4498697
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$153.09 |
| Max. Negotiated Rate |
$3,160.00 |
| Rate for Payer: Aetna Commercial |
$711.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$679.40
|
| Rate for Payer: Aetna Managed Medicare |
$221.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$153.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$153.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$153.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$418.70
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$726.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$442.08
|
| Rate for Payer: Health EOS Commercial |
$703.10
|
| Rate for Payer: HFN Commercial |
$726.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$592.50
|
| Rate for Payer: Multiplan Commercial |
$632.00
|
| Rate for Payer: NAPHCARE Commercial |
$474.00
|
| Rate for Payer: Preferred Network Access Commercial |
$726.80
|
| Rate for Payer: Quartz Beloit One Network |
$387.10
|
| Rate for Payer: Quartz Commercial |
$513.50
|
| Rate for Payer: Quartz Medicare Advantage |
$474.00
|
| Rate for Payer: The Alliance Commercial |
$3,160.00
|
| Rate for Payer: WEA Trust Commercial |
$434.50
|
| Rate for Payer: WPS Commercial |
$585.15
|
|
|
Pneuma/vac walk boot pre ots L4361
|
Professional
|
Both
|
$790.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
4498697
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$347.60 |
| Max. Negotiated Rate |
$917.41 |
| Rate for Payer: Aetna Commercial |
$750.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$679.40
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$750.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$395.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$474.00
|
| Rate for Payer: Health EOS Commercial |
$718.90
|
| Rate for Payer: HFN Commercial |
$750.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$917.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$917.41
|
| Rate for Payer: Multiplan Commercial |
$632.00
|
| Rate for Payer: Preferred Network Access Commercial |
$750.50
|
| Rate for Payer: Quartz Beloit One Network |
$347.60
|
| Rate for Payer: Quartz Commercial |
$450.30
|
| Rate for Payer: The Alliance Commercial |
$395.00
|
| Rate for Payer: WEA Trust Commercial |
$434.50
|
| Rate for Payer: WPS Commercial |
$585.15
|
|
