|
POWERSTEP PROTECH 3/4 A M 5-6.5, W 7-8.5 1005-03A
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2969910
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
POWERSTEP PROTECH 3/4 ASM M 4-4.5, W 6-6.5 1005-03AS
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2969915
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
POWERSTEP PROTECH 3/4 ASM M 4-4.5, W 6-6.5 1005-03AS
|
Facility
|
IP
|
$354.00
|
|
| Hospital Charge Code |
2969915
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
POWERSTEP PROTECH 3/4 B M 7-8.5,W 9-10.5 1005-03B
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2969912
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
POWERSTEP PROTECH 3/4 B M 7-8.5,W 9-10.5 1005-03B
|
Facility
|
IP
|
$354.00
|
|
| Hospital Charge Code |
2969912
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
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 |
$10.75 |
| Max. Negotiated Rate |
$50.39 |
| Rate for Payer: Aetna Commercial |
$50.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$10.75
|
| Rate for Payer: Anthem Medicare Advantage |
$10.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.75
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$50.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.75
|
| Rate for Payer: Health EOS Commercial |
$48.27
|
| Rate for Payer: HFN Commercial |
$50.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.75
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$16.13
|
| Rate for Payer: Preferred Network Access Commercial |
$50.39
|
| Rate for Payer: Quartz Beloit One Network |
$23.34
|
| Rate for Payer: Quartz Commercial |
$30.23
|
| Rate for Payer: Quartz Medicare Advantage |
$10.75
|
| Rate for Payer: The Alliance Commercial |
$42.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.75
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$47.32
|
|
|
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 |
$25.99 |
| Max. Negotiated Rate |
$121.76 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$30.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$114.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.81
|
| Rate for Payer: Anthem Medicare Advantage |
$30.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.44
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30.44
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30.44
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$45.66
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$34.48
|
| Rate for Payer: Quartz Medicare Advantage |
$30.44
|
| Rate for Payer: The Alliance Commercial |
$121.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.44
|
| Rate for Payer: United Healthcare PPO |
$39.78
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: Wellcare Medicare |
$30.44
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
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 |
$25.99 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$31.82
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
PPT INSOLES MEN 9-10
|
Facility
|
OP
|
$407.00
|
|
| Hospital Charge Code |
2971088
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$118.52 |
| Max. Negotiated Rate |
$389.42 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$364.02
|
| Rate for Payer: Aetna Managed Medicare |
$118.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$275.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$211.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$203.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$224.34
|
| Rate for Payer: Cash Price |
$122.10
|
| Rate for Payer: Cigna Commercial |
$389.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.87
|
| Rate for Payer: Health EOS Commercial |
$376.72
|
| Rate for Payer: HFN Commercial |
$389.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$317.46
|
| Rate for Payer: Multiplan Commercial |
$338.62
|
| Rate for Payer: NAPHCARE Commercial |
$253.97
|
| Rate for Payer: Preferred Network Access Commercial |
$389.42
|
| Rate for Payer: Quartz Beloit One Network |
$207.41
|
| Rate for Payer: Quartz Commercial |
$275.13
|
| Rate for Payer: Quartz Medicare Advantage |
$253.97
|
| Rate for Payer: The Alliance Commercial |
$211.64
|
| Rate for Payer: WEA Trust Commercial |
$232.80
|
| Rate for Payer: WPS Commercial |
$313.51
|
|
|
PPT INSOLES MEN 9-10
|
Facility
|
IP
|
$407.00
|
|
| Hospital Charge Code |
2971088
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$207.41 |
| Max. Negotiated Rate |
$389.42 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$364.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$224.34
|
| Rate for Payer: Cash Price |
$122.10
|
| Rate for Payer: Cigna Commercial |
$389.42
|
| Rate for Payer: Health EOS Commercial |
$376.72
|
| Rate for Payer: HFN Commercial |
$389.42
|
| Rate for Payer: Multiplan Commercial |
$338.62
|
| Rate for Payer: Preferred Network Access Commercial |
$389.42
|
| Rate for Payer: Quartz Beloit One Network |
$207.41
|
| Rate for Payer: Quartz Commercial |
$253.97
|
| Rate for Payer: WEA Trust Commercial |
$232.80
|
| Rate for Payer: WPS Commercial |
$313.51
|
|
|
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 |
$248.18 |
| Max. Negotiated Rate |
$465.96 |
| Rate for Payer: Aetna Commercial |
$455.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$435.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.43
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cigna Commercial |
$465.96
|
| Rate for Payer: Health EOS Commercial |
$450.77
|
| Rate for Payer: HFN Commercial |
$465.96
|
| Rate for Payer: Multiplan Commercial |
$405.18
|
| Rate for Payer: Preferred Network Access Commercial |
$465.96
|
| Rate for Payer: Quartz Beloit One Network |
$248.18
|
| Rate for Payer: Quartz Commercial |
$303.89
|
| Rate for Payer: WEA Trust Commercial |
$278.56
|
| Rate for Payer: WPS Commercial |
$375.14
|
|
|
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 |
$53.11 |
| Max. Negotiated Rate |
$465.96 |
| Rate for Payer: Aetna Commercial |
$455.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$435.57
|
| Rate for Payer: Aetna Managed Medicare |
$53.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$199.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.17
|
| Rate for Payer: Anthem Medicare Advantage |
$53.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.11
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cigna Commercial |
$465.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$53.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$283.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$53.11
|
| Rate for Payer: Health EOS Commercial |
$450.77
|
| Rate for Payer: HFN Commercial |
$465.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$197.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$53.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$53.11
|
| Rate for Payer: Multiplan Commercial |
$405.18
|
| Rate for Payer: NAPHCARE Commercial |
$79.67
|
| Rate for Payer: Preferred Network Access Commercial |
$465.96
|
| Rate for Payer: Quartz Beloit One Network |
$248.18
|
| Rate for Payer: Quartz Commercial |
$329.21
|
| Rate for Payer: Quartz Medicare Advantage |
$53.11
|
| Rate for Payer: The Alliance Commercial |
$212.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.11
|
| Rate for Payer: United Healthcare PPO |
$379.86
|
| Rate for Payer: WEA Trust Commercial |
$278.56
|
| Rate for Payer: Wellcare Medicare |
$53.11
|
| Rate for Payer: WPS Commercial |
$375.14
|
|
|
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 |
$53.11 |
| Max. Negotiated Rate |
$481.16 |
| Rate for Payer: Aetna Commercial |
$481.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$435.57
|
| Rate for Payer: Aetna Managed Medicare |
$53.11
|
| Rate for Payer: Anthem Medicare Advantage |
$53.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.11
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cash Price |
$146.10
|
| Rate for Payer: Cigna Commercial |
$481.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$253.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.11
|
| Rate for Payer: Health EOS Commercial |
$460.90
|
| Rate for Payer: HFN Commercial |
$481.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.11
|
| Rate for Payer: Multiplan Commercial |
$405.18
|
| Rate for Payer: NAPHCARE Commercial |
$79.67
|
| Rate for Payer: Preferred Network Access Commercial |
$481.16
|
| Rate for Payer: Quartz Beloit One Network |
$222.85
|
| Rate for Payer: Quartz Commercial |
$288.69
|
| Rate for Payer: Quartz Medicare Advantage |
$53.11
|
| Rate for Payer: The Alliance Commercial |
$209.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.11
|
| Rate for Payer: WEA Trust Commercial |
$278.56
|
| Rate for Payer: WPS Commercial |
$233.70
|
|
|
PRAFO - PT Equipment Issued Rehab
|
Professional
|
Both
|
$988.00
|
|
|
Service Code
|
HCPCS L1930
|
| Hospital Charge Code |
2989873
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$321.98 |
| Max. Negotiated Rate |
$976.14 |
| Rate for Payer: Aetna Commercial |
$976.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$883.67
|
| Rate for Payer: Aetna Managed Medicare |
$321.98
|
| Rate for Payer: Anthem Medicare Advantage |
$321.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$321.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$321.98
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$976.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$513.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.98
|
| Rate for Payer: Health EOS Commercial |
$935.04
|
| Rate for Payer: HFN Commercial |
$976.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$928.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$928.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$321.98
|
| Rate for Payer: Multiplan Commercial |
$822.02
|
| Rate for Payer: NAPHCARE Commercial |
$482.98
|
| Rate for Payer: Preferred Network Access Commercial |
$976.14
|
| Rate for Payer: Quartz Beloit One Network |
$452.11
|
| Rate for Payer: Quartz Commercial |
$585.69
|
| Rate for Payer: Quartz Medicare Advantage |
$321.98
|
| Rate for Payer: The Alliance Commercial |
$885.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$321.98
|
| Rate for Payer: WEA Trust Commercial |
$565.14
|
| Rate for Payer: WPS Commercial |
$563.47
|
|
|
PRAFO - PT Equipment Issued Rehab
|
Facility
|
OP
|
$988.00
|
|
|
Service Code
|
HCPCS L1930
|
| Hospital Charge Code |
2989873
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$176.35 |
| Max. Negotiated Rate |
$1,287.94 |
| Rate for Payer: Aetna Commercial |
$924.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$883.67
|
| Rate for Payer: Aetna Managed Medicare |
$287.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$176.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$544.59
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$945.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$575.02
|
| Rate for Payer: Health EOS Commercial |
$914.49
|
| Rate for Payer: HFN Commercial |
$945.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$770.64
|
| Rate for Payer: Multiplan Commercial |
$822.02
|
| Rate for Payer: NAPHCARE Commercial |
$616.51
|
| Rate for Payer: Preferred Network Access Commercial |
$945.32
|
| Rate for Payer: Quartz Beloit One Network |
$503.48
|
| Rate for Payer: Quartz Commercial |
$667.89
|
| Rate for Payer: Quartz Medicare Advantage |
$616.51
|
| Rate for Payer: The Alliance Commercial |
$1,287.94
|
| Rate for Payer: WEA Trust Commercial |
$565.14
|
| Rate for Payer: WPS Commercial |
$761.06
|
|
|
PRAFO - PT Equipment Issued Rehab
|
Facility
|
IP
|
$988.00
|
|
|
Service Code
|
HCPCS L1930
|
| Hospital Charge Code |
2989873
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$503.48 |
| Max. Negotiated Rate |
$945.32 |
| Rate for Payer: Aetna Commercial |
$924.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$883.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$544.59
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$945.32
|
| Rate for Payer: Health EOS Commercial |
$914.49
|
| Rate for Payer: HFN Commercial |
$945.32
|
| Rate for Payer: Multiplan Commercial |
$822.02
|
| Rate for Payer: Preferred Network Access Commercial |
$945.32
|
| Rate for Payer: Quartz Beloit One Network |
$503.48
|
| Rate for Payer: Quartz Commercial |
$616.51
|
| Rate for Payer: WEA Trust Commercial |
$565.14
|
| Rate for Payer: WPS Commercial |
$761.06
|
|
|
Prealbumin
|
Professional
|
Both
|
$413.00
|
|
|
Service Code
|
CPT 84134
|
| Hospital Charge Code |
978043
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.17 |
| Max. Negotiated Rate |
$408.04 |
| Rate for Payer: Aetna Commercial |
$408.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.39
|
| Rate for Payer: Aetna Managed Medicare |
$15.17
|
| Rate for Payer: Anthem Medicare Advantage |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.17
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: Cigna Commercial |
$408.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$214.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.17
|
| Rate for Payer: Health EOS Commercial |
$390.86
|
| Rate for Payer: HFN Commercial |
$408.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.17
|
| Rate for Payer: Multiplan Commercial |
$343.62
|
| Rate for Payer: NAPHCARE Commercial |
$22.76
|
| Rate for Payer: Preferred Network Access Commercial |
$408.04
|
| Rate for Payer: Quartz Beloit One Network |
$188.99
|
| Rate for Payer: Quartz Commercial |
$244.83
|
| Rate for Payer: Quartz Medicare Advantage |
$15.17
|
| Rate for Payer: The Alliance Commercial |
$59.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.17
|
| Rate for Payer: WEA Trust Commercial |
$236.24
|
| Rate for Payer: WPS Commercial |
$66.76
|
|
