|
POWERSTEP PROTECH 3/4 C M 9-9.5, W 11-11.5 1005-03C
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2969913
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Aetna Managed Medicare |
$99.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$230.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$177.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.10
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.50
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$230.10
|
| Rate for Payer: Quartz Medicare Advantage |
$212.40
|
| Rate for Payer: The Alliance Commercial |
$1,416.00
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
POWERSTEP PROTECH 3/4 C M 9-9.5, W 11-11.5 1005-03C
|
Facility
|
IP
|
$354.00
|
|
| Hospital Charge Code |
2969913
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$173.46 |
| Max. Negotiated Rate |
$325.68 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$212.40
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
POWERSTEP PROTECH 3/4 D M 10-10.5, W 12 1005-03D
|
Facility
|
IP
|
$354.00
|
|
| Hospital Charge Code |
2969911
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$173.46 |
| Max. Negotiated Rate |
$325.68 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$212.40
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
POWERSTEP PROTECH 3/4 D M 10-10.5, W 12 1005-03D
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2969911
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Aetna Managed Medicare |
$99.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$230.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$177.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.10
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.50
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$230.10
|
| Rate for Payer: Quartz Medicare Advantage |
$212.40
|
| Rate for Payer: The Alliance Commercial |
$1,416.00
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
POWERSTEP PROTECH 3/4 E M 11-11.5 1005-03E
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2969916
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Aetna Managed Medicare |
$99.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$230.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$177.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.10
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.50
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$230.10
|
| Rate for Payer: Quartz Medicare Advantage |
$212.40
|
| Rate for Payer: The Alliance Commercial |
$1,416.00
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
POWERSTEP PROTECH 3/4 E M 11-11.5 1005-03E
|
Facility
|
IP
|
$354.00
|
|
| Hospital Charge Code |
2969916
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$173.46 |
| Max. Negotiated Rate |
$325.68 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$212.40
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
POWERSTEP PROTECH 3/4 F M 12-13 1005-03F
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2969917
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Aetna Managed Medicare |
$99.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$230.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$177.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.10
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.50
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$230.10
|
| Rate for Payer: Quartz Medicare Advantage |
$212.40
|
| Rate for Payer: The Alliance Commercial |
$1,416.00
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
POWERSTEP PROTECH 3/4 F M 12-13 1005-03F
|
Facility
|
IP
|
$354.00
|
|
| Hospital Charge Code |
2969917
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$173.46 |
| Max. Negotiated Rate |
$325.68 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$212.40
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
PPD Charge 86580 - PPD Admin Charge
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3626171
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$117.72 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Aetna Managed Medicare |
$29.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.85
|
| Rate for Payer: Anthem Medicare Advantage |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.43
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29.43
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29.43
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$44.14
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$33.15
|
| Rate for Payer: Quartz Medicare Advantage |
$29.43
|
| Rate for Payer: The Alliance Commercial |
$117.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.43
|
| Rate for Payer: United Healthcare PPO |
$38.25
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: Wellcare Medicare |
$29.43
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
PPD Charge 86580 - PPD Admin Charge
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3626171
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$46.92 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$30.60
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
PPD Charge 86580 - PPD Admin Charge
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
3626171
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.60
|
| Rate for Payer: Health EOS Commercial |
$46.41
|
| Rate for Payer: HFN Commercial |
$48.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.86
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.45
|
| Rate for Payer: Quartz Beloit One Network |
$22.44
|
| Rate for Payer: Quartz Commercial |
$29.07
|
| Rate for Payer: The Alliance Commercial |
$25.50
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
PPT INSOLES MEN 9-10
|
Facility
|
OP
|
$407.00
|
|
| Hospital Charge Code |
2971088
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.96 |
| Max. Negotiated Rate |
$1,628.00 |
| Rate for Payer: Aetna Commercial |
$366.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$350.02
|
| Rate for Payer: Aetna Managed Medicare |
$113.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$264.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$203.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$195.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.71
|
| Rate for Payer: Cash Price |
$122.10
|
| Rate for Payer: Cigna Commercial |
$374.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.76
|
| Rate for Payer: Health EOS Commercial |
$362.23
|
| Rate for Payer: HFN Commercial |
$374.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$305.25
|
| Rate for Payer: Multiplan Commercial |
$325.60
|
| Rate for Payer: NAPHCARE Commercial |
$244.20
|
| Rate for Payer: Preferred Network Access Commercial |
$374.44
|
| Rate for Payer: Quartz Beloit One Network |
$199.43
|
| Rate for Payer: Quartz Commercial |
$264.55
|
| Rate for Payer: Quartz Medicare Advantage |
$244.20
|
| Rate for Payer: The Alliance Commercial |
$1,628.00
|
| Rate for Payer: WEA Trust Commercial |
$223.85
|
| Rate for Payer: WPS Commercial |
$301.46
|
|
|
PPT INSOLES MEN 9-10
|
Facility
|
IP
|
$407.00
|
|
| Hospital Charge Code |
2971088
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$199.43 |
| Max. Negotiated Rate |
$374.44 |
| Rate for Payer: Aetna Commercial |
$366.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$350.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.71
|
| Rate for Payer: Cash Price |
$122.10
|
| Rate for Payer: Cigna Commercial |
$374.44
|
| Rate for Payer: Health EOS Commercial |
$362.23
|
| Rate for Payer: HFN Commercial |
$374.44
|
| Rate for Payer: Multiplan Commercial |
$325.60
|
| Rate for Payer: NAPHCARE Commercial |
$244.20
|
| Rate for Payer: Preferred Network Access Commercial |
$374.44
|
| Rate for Payer: Quartz Beloit One Network |
$199.43
|
| Rate for Payer: Quartz Commercial |
$244.20
|
| Rate for Payer: WEA Trust Commercial |
$223.85
|
| Rate for Payer: WPS Commercial |
$301.46
|
|
|
Prader-Willi/Angelman Syndrome, DNA Methylation
|
Facility
|
IP
|
$487.00
|
|
|
Service Code
|
CPT 81331
|
| Hospital Charge Code |
5506874
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$238.63 |
| Max. Negotiated Rate |
$448.04 |
| Rate for Payer: Aetna Commercial |
$438.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$418.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$258.11
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cigna Commercial |
$448.04
|
| Rate for Payer: Health EOS Commercial |
$433.43
|
| Rate for Payer: HFN Commercial |
$448.04
|
| Rate for Payer: Multiplan Commercial |
$389.60
|
| Rate for Payer: NAPHCARE Commercial |
$292.20
|
| Rate for Payer: Preferred Network Access Commercial |
$448.04
|
| Rate for Payer: Quartz Beloit One Network |
$238.63
|
| Rate for Payer: Quartz Commercial |
$292.20
|
| Rate for Payer: WEA Trust Commercial |
$267.85
|
| Rate for Payer: WPS Commercial |
$360.72
|
|
|
Prader-Willi/Angelman Syndrome, DNA Methylation
|
Professional
|
Both
|
$487.00
|
|
|
Service Code
|
CPT 81331
|
| Hospital Charge Code |
5506874
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$180.28 |
| Max. Negotiated Rate |
$462.65 |
| Rate for Payer: Aetna Commercial |
$462.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$418.82
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cigna Commercial |
$462.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$243.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$292.20
|
| Rate for Payer: Health EOS Commercial |
$443.17
|
| Rate for Payer: HFN Commercial |
$462.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$180.28
|
| Rate for Payer: Multiplan Commercial |
$389.60
|
| Rate for Payer: Preferred Network Access Commercial |
$462.65
|
| Rate for Payer: Quartz Beloit One Network |
$214.28
|
| Rate for Payer: Quartz Commercial |
$277.59
|
| Rate for Payer: The Alliance Commercial |
$243.50
|
| Rate for Payer: WEA Trust Commercial |
$267.85
|
| Rate for Payer: WPS Commercial |
$360.72
|
|
|
Prader-Willi/Angelman Syndrome, DNA Methylation
|
Facility
|
OP
|
$487.00
|
|
|
Service Code
|
CPT 81331
|
| Hospital Charge Code |
5506874
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.07 |
| Max. Negotiated Rate |
$448.04 |
| Rate for Payer: Aetna Commercial |
$438.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$418.82
|
| Rate for Payer: Aetna Managed Medicare |
$51.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$191.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$89.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.78
|
| Rate for Payer: Anthem Medicaid |
$52.77
|
| Rate for Payer: Anthem Medicare Advantage |
$51.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$258.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$51.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$51.07
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cigna Commercial |
$448.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$51.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$272.53
|
| Rate for Payer: Dean Health Medicaid |
$52.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$51.07
|
| Rate for Payer: Health EOS Commercial |
$433.43
|
| Rate for Payer: HFN Commercial |
$448.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$52.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$51.07
|
| Rate for Payer: Managed Health Services Medicaid |
$54.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$51.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$51.07
|
| Rate for Payer: Multiplan Commercial |
$389.60
|
| Rate for Payer: NAPHCARE Commercial |
$76.60
|
| Rate for Payer: Preferred Network Access Commercial |
$448.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$52.77
|
| Rate for Payer: Quartz Beloit One Network |
$238.63
|
| Rate for Payer: Quartz Commercial |
$316.55
|
| Rate for Payer: Quartz Medicare Advantage |
$51.07
|
| Rate for Payer: The Alliance Commercial |
$204.28
|
| Rate for Payer: United Healthcare Medicaid |
$52.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.07
|
| Rate for Payer: United Healthcare PPO |
$365.25
|
| Rate for Payer: WEA Trust Commercial |
$267.85
|
| Rate for Payer: Wellcare Medicare |
$51.07
|
| Rate for Payer: WMAP Medicaid |
$52.77
|
| Rate for Payer: WPS Commercial |
$360.72
|
|
|
PRAFO - PT Equipment Issued Rehab
|
Facility
|
IP
|
$988.00
|
|
|
Service Code
|
HCPCS L1930
|
| Hospital Charge Code |
2989873
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$484.12 |
| Max. Negotiated Rate |
$908.96 |
| Rate for Payer: Aetna Commercial |
$889.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$849.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$523.64
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$908.96
|
| Rate for Payer: Health EOS Commercial |
$879.32
|
| Rate for Payer: HFN Commercial |
$908.96
|
| Rate for Payer: Multiplan Commercial |
$790.40
|
| Rate for Payer: NAPHCARE Commercial |
$592.80
|
| Rate for Payer: Preferred Network Access Commercial |
$908.96
|
| Rate for Payer: Quartz Beloit One Network |
$484.12
|
| Rate for Payer: Quartz Commercial |
$592.80
|
| Rate for Payer: WEA Trust Commercial |
$543.40
|
| Rate for Payer: WPS Commercial |
$731.81
|
|
|
PRAFO - PT Equipment Issued Rehab
|
Professional
|
Both
|
$988.00
|
|
|
Service Code
|
HCPCS L1930
|
| Hospital Charge Code |
2989873
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$434.72 |
| Max. Negotiated Rate |
$938.60 |
| Rate for Payer: Aetna Commercial |
$938.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$849.68
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$938.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$494.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$592.80
|
| Rate for Payer: Health EOS Commercial |
$899.08
|
| Rate for Payer: HFN Commercial |
$938.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$892.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$892.70
|
| Rate for Payer: Multiplan Commercial |
$790.40
|
| Rate for Payer: Preferred Network Access Commercial |
$938.60
|
| Rate for Payer: Quartz Beloit One Network |
$434.72
|
| Rate for Payer: Quartz Commercial |
$563.16
|
| Rate for Payer: The Alliance Commercial |
$494.00
|
| Rate for Payer: WEA Trust Commercial |
$543.40
|
| Rate for Payer: WPS Commercial |
$731.81
|
|
|
PRAFO - PT Equipment Issued Rehab
|
Facility
|
OP
|
$988.00
|
|
|
Service Code
|
HCPCS L1930
|
| Hospital Charge Code |
2989873
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$169.57 |
| Max. Negotiated Rate |
$3,952.00 |
| Rate for Payer: Aetna Commercial |
$889.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$849.68
|
| Rate for Payer: Aetna Managed Medicare |
$276.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$169.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$169.57
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$523.64
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$908.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$552.88
|
| Rate for Payer: Health EOS Commercial |
$879.32
|
| Rate for Payer: HFN Commercial |
$908.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$741.00
|
| Rate for Payer: Multiplan Commercial |
$790.40
|
| Rate for Payer: NAPHCARE Commercial |
$592.80
|
| Rate for Payer: Preferred Network Access Commercial |
$908.96
|
| Rate for Payer: Quartz Beloit One Network |
$484.12
|
| Rate for Payer: Quartz Commercial |
$642.20
|
| Rate for Payer: Quartz Medicare Advantage |
$592.80
|
| Rate for Payer: The Alliance Commercial |
$3,952.00
|
| Rate for Payer: WEA Trust Commercial |
$543.40
|
| Rate for Payer: WPS Commercial |
$731.81
|
|
|
Prealbumin
|
Professional
|
Both
|
$413.00
|
|
|
Service Code
|
CPT 84134
|
| Hospital Charge Code |
978043
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$392.35 |
| Rate for Payer: Aetna Commercial |
$392.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.18
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$392.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.80
|
| Rate for Payer: Health EOS Commercial |
$375.83
|
| Rate for Payer: HFN Commercial |
$392.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.50
|
| Rate for Payer: Multiplan Commercial |
$330.40
|
| Rate for Payer: Preferred Network Access Commercial |
$392.35
|
| Rate for Payer: Quartz Beloit One Network |
$181.72
|
| Rate for Payer: Quartz Commercial |
$235.41
|
| Rate for Payer: The Alliance Commercial |
$206.50
|
| Rate for Payer: WEA Trust Commercial |
$227.15
|
| Rate for Payer: WPS Commercial |
$305.91
|
|
|
Prealbumin
|
Facility
|
OP
|
$413.00
|
|
|
Service Code
|
CPT 84134
|
| Hospital Charge Code |
978043
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$379.96 |
| Rate for Payer: Aetna Commercial |
$371.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.18
|
| Rate for Payer: Aetna Managed Medicare |
$14.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.53
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.22
|
| Rate for Payer: Anthem Medicaid |
$7.85
|
| Rate for Payer: Anthem Medicare Advantage |
$14.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.59
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$379.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.11
|
| Rate for Payer: Dean Health Medicaid |
$7.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.59
|
| Rate for Payer: Health EOS Commercial |
$367.57
|
| Rate for Payer: HFN Commercial |
$379.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.59
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.59
|
| Rate for Payer: Managed Health Services Medicaid |
$8.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.59
|
| Rate for Payer: Multiplan Commercial |
$330.40
|
| Rate for Payer: NAPHCARE Commercial |
$21.88
|
| Rate for Payer: Preferred Network Access Commercial |
$379.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.85
|
| Rate for Payer: Quartz Beloit One Network |
$202.37
|
| Rate for Payer: Quartz Commercial |
$268.45
|
| Rate for Payer: Quartz Medicare Advantage |
$14.59
|
| Rate for Payer: The Alliance Commercial |
$58.36
|
| Rate for Payer: United Healthcare Medicaid |
$7.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.59
|
| Rate for Payer: United Healthcare PPO |
$309.75
|
| Rate for Payer: WEA Trust Commercial |
$227.15
|
| Rate for Payer: Wellcare Medicare |
$14.59
|
| Rate for Payer: WMAP Medicaid |
$7.85
|
| Rate for Payer: WPS Commercial |
$305.91
|
|
|
Prealbumin
|
Facility
|
IP
|
$413.00
|
|
|
Service Code
|
CPT 84134
|
| Hospital Charge Code |
978043
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$202.37 |
| Max. Negotiated Rate |
$379.96 |
| Rate for Payer: Aetna Commercial |
$371.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.89
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$379.96
|
| Rate for Payer: Health EOS Commercial |
$367.57
|
| Rate for Payer: HFN Commercial |
$379.96
|
| Rate for Payer: Multiplan Commercial |
$330.40
|
| Rate for Payer: NAPHCARE Commercial |
$247.80
|
| Rate for Payer: Preferred Network Access Commercial |
$379.96
|
| Rate for Payer: Quartz Beloit One Network |
$202.37
|
| Rate for Payer: Quartz Commercial |
$247.80
|
| Rate for Payer: WEA Trust Commercial |
$227.15
|
| Rate for Payer: WPS Commercial |
$305.91
|
|
|
Pre and Post - Pulmonary Function Test Charge
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
CPT 94060
|
| Hospital Charge Code |
3006993
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$257.76 |
| Max. Negotiated Rate |
$1,240.96 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Aetna Managed Medicare |
$310.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$268.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$257.76
|
| Rate for Payer: Anthem Medicare Advantage |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$310.24
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$310.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.51
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$310.24
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,154.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$310.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$310.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$310.24
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$465.36
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$349.05
|
| Rate for Payer: Quartz Medicare Advantage |
$310.24
|
| Rate for Payer: The Alliance Commercial |
$1,240.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$310.24
|
| Rate for Payer: United Healthcare PPO |
$402.75
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: Wellcare Medicare |
$310.24
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
Pre and Post - Pulmonary Function Test Charge
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
CPT 94060
|
| Hospital Charge Code |
3006993
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$263.13 |
| Max. Negotiated Rate |
$494.04 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$322.20
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
PRECISION PIN GAMMA4 3.2/3.9 X 450MM TAPERED 1420-0065S
|
Facility
|
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
6181748
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,266.25 |
| Max. Negotiated Rate |
$4,255.00 |
| Rate for Payer: Aetna Commercial |
$4,162.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,977.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,451.25
|
| Rate for Payer: Cash Price |
$1,387.50
|
| Rate for Payer: Cigna Commercial |
$4,255.00
|
| Rate for Payer: Health EOS Commercial |
$4,116.25
|
| Rate for Payer: HFN Commercial |
$4,255.00
|
| Rate for Payer: Multiplan Commercial |
$3,700.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,775.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,255.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,266.25
|
| Rate for Payer: Quartz Commercial |
$2,775.00
|
| Rate for Payer: WEA Trust Commercial |
$2,543.75
|
| Rate for Payer: WPS Commercial |
$3,425.74
|
|
