|
PMIC/ID109
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313515
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
PMP22 DNA Sequencing
|
Facility
|
OP
|
$3,172.00
|
|
|
Service Code
|
CPT 81325
|
| Hospital Charge Code |
5273723
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$800.36 |
| Max. Negotiated Rate |
$3,201.45 |
| Rate for Payer: Aetna Commercial |
$2,968.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,837.04
|
| Rate for Payer: Aetna Managed Medicare |
$800.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,001.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,400.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,328.60
|
| Rate for Payer: Anthem Medicare Advantage |
$800.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,748.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$800.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$800.36
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cigna Commercial |
$3,034.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$800.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,846.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$800.36
|
| Rate for Payer: Health EOS Commercial |
$2,936.00
|
| Rate for Payer: HFN Commercial |
$3,034.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,977.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$800.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$800.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$800.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$800.36
|
| Rate for Payer: Multiplan Commercial |
$2,639.10
|
| Rate for Payer: NAPHCARE Commercial |
$1,200.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,034.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,616.45
|
| Rate for Payer: Quartz Commercial |
$2,144.27
|
| Rate for Payer: Quartz Medicare Advantage |
$800.36
|
| Rate for Payer: The Alliance Commercial |
$3,201.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$800.36
|
| Rate for Payer: United Healthcare PPO |
$2,474.16
|
| Rate for Payer: WEA Trust Commercial |
$1,814.38
|
| Rate for Payer: Wellcare Medicare |
$800.36
|
| Rate for Payer: WPS Commercial |
$2,443.39
|
|
|
PMP22 DNA Sequencing
|
Facility
|
IP
|
$3,172.00
|
|
|
Service Code
|
CPT 81325
|
| Hospital Charge Code |
5273723
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,616.45 |
| Max. Negotiated Rate |
$3,034.97 |
| Rate for Payer: Aetna Commercial |
$2,968.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,837.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,748.41
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cigna Commercial |
$3,034.97
|
| Rate for Payer: Health EOS Commercial |
$2,936.00
|
| Rate for Payer: HFN Commercial |
$3,034.97
|
| Rate for Payer: Multiplan Commercial |
$2,639.10
|
| Rate for Payer: Preferred Network Access Commercial |
$3,034.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,616.45
|
| Rate for Payer: Quartz Commercial |
$1,979.33
|
| Rate for Payer: WEA Trust Commercial |
$1,814.38
|
| Rate for Payer: WPS Commercial |
$2,443.39
|
|
|
PMP22 DNA Sequencing
|
Professional
|
Both
|
$3,172.00
|
|
|
Service Code
|
CPT 81325
|
| Hospital Charge Code |
5273723
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$800.36 |
| Max. Negotiated Rate |
$3,521.60 |
| Rate for Payer: Aetna Commercial |
$3,133.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,837.04
|
| Rate for Payer: Aetna Managed Medicare |
$800.36
|
| Rate for Payer: Anthem Medicare Advantage |
$800.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$800.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$800.36
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cigna Commercial |
$3,133.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,649.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$800.36
|
| Rate for Payer: Health EOS Commercial |
$3,001.98
|
| Rate for Payer: HFN Commercial |
$3,133.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,825.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,825.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$800.36
|
| Rate for Payer: Multiplan Commercial |
$2,639.10
|
| Rate for Payer: NAPHCARE Commercial |
$1,200.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,133.94
|
| Rate for Payer: Quartz Beloit One Network |
$1,451.51
|
| Rate for Payer: Quartz Commercial |
$1,880.36
|
| Rate for Payer: Quartz Medicare Advantage |
$800.36
|
| Rate for Payer: The Alliance Commercial |
$3,161.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$800.36
|
| Rate for Payer: WEA Trust Commercial |
$1,814.38
|
| Rate for Payer: WPS Commercial |
$3,521.60
|
|
|
PMS2
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
CPT 81317
|
| Hospital Charge Code |
5542927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$305.68 |
| Max. Negotiated Rate |
$3,095.66 |
| Rate for Payer: Aetna Commercial |
$659.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$597.46
|
| Rate for Payer: Aetna Managed Medicare |
$703.56
|
| Rate for Payer: Anthem Medicare Advantage |
$703.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$703.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$703.56
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$659.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$347.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$703.56
|
| Rate for Payer: Health EOS Commercial |
$632.20
|
| Rate for Payer: HFN Commercial |
$659.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,483.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,483.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$703.56
|
| Rate for Payer: Multiplan Commercial |
$555.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,055.34
|
| Rate for Payer: Preferred Network Access Commercial |
$659.98
|
| Rate for Payer: Quartz Beloit One Network |
$305.68
|
| Rate for Payer: Quartz Commercial |
$395.99
|
| Rate for Payer: Quartz Medicare Advantage |
$703.56
|
| Rate for Payer: The Alliance Commercial |
$2,779.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$703.56
|
| Rate for Payer: WEA Trust Commercial |
$382.10
|
| Rate for Payer: WPS Commercial |
$3,095.66
|
|
|
PMS2
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 81317
|
| Hospital Charge Code |
5542927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$340.41 |
| Max. Negotiated Rate |
$639.14 |
| Rate for Payer: Aetna Commercial |
$625.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$597.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$368.20
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$639.14
|
| Rate for Payer: Health EOS Commercial |
$618.30
|
| Rate for Payer: HFN Commercial |
$639.14
|
| Rate for Payer: Multiplan Commercial |
$555.78
|
| Rate for Payer: Preferred Network Access Commercial |
$639.14
|
| Rate for Payer: Quartz Beloit One Network |
$340.41
|
| Rate for Payer: Quartz Commercial |
$416.83
|
| Rate for Payer: WEA Trust Commercial |
$382.10
|
| Rate for Payer: WPS Commercial |
$514.56
|
|
|
PMS2
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 81317
|
| Hospital Charge Code |
5542927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$340.41 |
| Max. Negotiated Rate |
$2,814.24 |
| Rate for Payer: Aetna Commercial |
$625.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$597.46
|
| Rate for Payer: Aetna Managed Medicare |
$703.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,638.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,231.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,167.91
|
| Rate for Payer: Anthem Medicare Advantage |
$703.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$368.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$703.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$703.56
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$639.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$703.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$388.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$703.56
|
| Rate for Payer: Health EOS Commercial |
$618.30
|
| Rate for Payer: HFN Commercial |
$639.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,617.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$703.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$703.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$703.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$703.56
|
| Rate for Payer: Multiplan Commercial |
$555.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,055.34
|
| Rate for Payer: Preferred Network Access Commercial |
$639.14
|
| Rate for Payer: Quartz Beloit One Network |
$340.41
|
| Rate for Payer: Quartz Commercial |
$451.57
|
| Rate for Payer: Quartz Medicare Advantage |
$703.56
|
| Rate for Payer: The Alliance Commercial |
$2,814.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$703.56
|
| Rate for Payer: United Healthcare PPO |
$521.04
|
| Rate for Payer: WEA Trust Commercial |
$382.10
|
| Rate for Payer: Wellcare Medicare |
$703.56
|
| Rate for Payer: WPS Commercial |
$514.56
|
|
|
PMS2 Dup/Del
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 81319
|
| Hospital Charge Code |
5542928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$340.41 |
| Max. Negotiated Rate |
$639.14 |
| Rate for Payer: Aetna Commercial |
$625.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$597.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$368.20
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$639.14
|
| Rate for Payer: Health EOS Commercial |
$618.30
|
| Rate for Payer: HFN Commercial |
$639.14
|
| Rate for Payer: Multiplan Commercial |
$555.78
|
| Rate for Payer: Preferred Network Access Commercial |
$639.14
|
| Rate for Payer: Quartz Beloit One Network |
$340.41
|
| Rate for Payer: Quartz Commercial |
$416.83
|
| Rate for Payer: WEA Trust Commercial |
$382.10
|
| Rate for Payer: WPS Commercial |
$514.56
|
|
|
PMS2 Dup/Del
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 81319
|
| Hospital Charge Code |
5542928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$211.64 |
| Max. Negotiated Rate |
$846.56 |
| Rate for Payer: Aetna Commercial |
$625.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$597.46
|
| Rate for Payer: Aetna Managed Medicare |
$211.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$793.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$370.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$351.32
|
| Rate for Payer: Anthem Medicare Advantage |
$211.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$368.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.64
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$639.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$211.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$388.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$211.64
|
| Rate for Payer: Health EOS Commercial |
$618.30
|
| Rate for Payer: HFN Commercial |
$639.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$787.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$211.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$211.64
|
| Rate for Payer: Multiplan Commercial |
$555.78
|
| Rate for Payer: NAPHCARE Commercial |
$317.46
|
| Rate for Payer: Preferred Network Access Commercial |
$639.14
|
| Rate for Payer: Quartz Beloit One Network |
$340.41
|
| Rate for Payer: Quartz Commercial |
$451.57
|
| Rate for Payer: Quartz Medicare Advantage |
$211.64
|
| Rate for Payer: The Alliance Commercial |
$846.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.64
|
| Rate for Payer: United Healthcare PPO |
$521.04
|
| Rate for Payer: WEA Trust Commercial |
$382.10
|
| Rate for Payer: Wellcare Medicare |
$211.64
|
| Rate for Payer: WPS Commercial |
$514.56
|
|
|
PMS2 Dup/Del
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
CPT 81319
|
| Hospital Charge Code |
5542928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$211.64 |
| Max. Negotiated Rate |
$931.22 |
| Rate for Payer: Aetna Commercial |
$659.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$597.46
|
| Rate for Payer: Aetna Managed Medicare |
$211.64
|
| Rate for Payer: Anthem Medicare Advantage |
$211.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.64
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$659.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$347.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$211.64
|
| Rate for Payer: Health EOS Commercial |
$632.20
|
| Rate for Payer: HFN Commercial |
$659.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$747.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$747.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.64
|
| Rate for Payer: Multiplan Commercial |
$555.78
|
| Rate for Payer: NAPHCARE Commercial |
$317.46
|
| Rate for Payer: Preferred Network Access Commercial |
$659.98
|
| Rate for Payer: Quartz Beloit One Network |
$305.68
|
| Rate for Payer: Quartz Commercial |
$395.99
|
| Rate for Payer: Quartz Medicare Advantage |
$211.64
|
| Rate for Payer: The Alliance Commercial |
$835.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.64
|
| Rate for Payer: WEA Trust Commercial |
$382.10
|
| Rate for Payer: WPS Commercial |
$931.22
|
|
|
PNEUMATIC WALKER (L) 01F-L
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
2972438
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$479.02 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$586.56
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
PNEUMATIC WALKER (L) 01F-L
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
2972438
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$273.73 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Aetna Managed Medicare |
$273.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$635.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$488.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$469.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.08
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$733.20
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: NAPHCARE Commercial |
$586.56
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$635.44
|
| Rate for Payer: Quartz Medicare Advantage |
$586.56
|
| Rate for Payer: The Alliance Commercial |
$488.80
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
PNEUMATIC WALKER (M) 01F-M
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
2972437
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$273.73 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Aetna Managed Medicare |
$273.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$635.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$488.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$469.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.08
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$733.20
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: NAPHCARE Commercial |
$586.56
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$635.44
|
| Rate for Payer: Quartz Medicare Advantage |
$586.56
|
| Rate for Payer: The Alliance Commercial |
$488.80
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
PNEUMATIC WALKER (M) 01F-M
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
2972437
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$479.02 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$586.56
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
PNEUMATIC WALKER (S) 01F-S
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
2972821
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$479.02 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$586.56
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
PNEUMATIC WALKER (S) 01F-S
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
2972821
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$273.73 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Aetna Managed Medicare |
$273.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$635.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$488.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$469.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.08
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$733.20
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: NAPHCARE Commercial |
$586.56
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$635.44
|
| Rate for Payer: Quartz Medicare Advantage |
$586.56
|
| Rate for Payer: The Alliance Commercial |
$488.80
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
PNEUMATIC WALK(L) SHORT 01A-L
|
Facility
|
OP
|
$872.00
|
|
| Hospital Charge Code |
2972440
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$253.93 |
| Max. Negotiated Rate |
$834.33 |
| Rate for Payer: Aetna Commercial |
$816.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$779.92
|
| Rate for Payer: Aetna Managed Medicare |
$253.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$589.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$453.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$435.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$480.65
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$834.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$507.50
|
| Rate for Payer: Health EOS Commercial |
$807.12
|
| Rate for Payer: HFN Commercial |
$834.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$680.16
|
| Rate for Payer: Multiplan Commercial |
$725.50
|
| Rate for Payer: NAPHCARE Commercial |
$544.13
|
| Rate for Payer: Preferred Network Access Commercial |
$834.33
|
| Rate for Payer: Quartz Beloit One Network |
$444.37
|
| Rate for Payer: Quartz Commercial |
$589.47
|
| Rate for Payer: Quartz Medicare Advantage |
$544.13
|
| Rate for Payer: The Alliance Commercial |
$453.44
|
| Rate for Payer: WEA Trust Commercial |
$498.78
|
| Rate for Payer: WPS Commercial |
$671.70
|
|
|
PNEUMATIC WALK(L) SHORT 01A-L
|
Facility
|
IP
|
$872.00
|
|
| Hospital Charge Code |
2972440
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$444.37 |
| Max. Negotiated Rate |
$834.33 |
| Rate for Payer: Aetna Commercial |
$816.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$779.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$480.65
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$834.33
|
| Rate for Payer: Health EOS Commercial |
$807.12
|
| Rate for Payer: HFN Commercial |
$834.33
|
| Rate for Payer: Multiplan Commercial |
$725.50
|
| Rate for Payer: Preferred Network Access Commercial |
$834.33
|
| Rate for Payer: Quartz Beloit One Network |
$444.37
|
| Rate for Payer: Quartz Commercial |
$544.13
|
| Rate for Payer: WEA Trust Commercial |
$498.78
|
| Rate for Payer: WPS Commercial |
$671.70
|
|
|
PNEUMATIC WALK(M) SHORT 01-AM
|
Facility
|
OP
|
$872.00
|
|
| Hospital Charge Code |
2972439
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$253.93 |
| Max. Negotiated Rate |
$834.33 |
| Rate for Payer: Aetna Commercial |
$816.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$779.92
|
| Rate for Payer: Aetna Managed Medicare |
$253.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$589.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$453.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$435.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$480.65
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$834.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$507.50
|
| Rate for Payer: Health EOS Commercial |
$807.12
|
| Rate for Payer: HFN Commercial |
$834.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$680.16
|
| Rate for Payer: Multiplan Commercial |
$725.50
|
| Rate for Payer: NAPHCARE Commercial |
$544.13
|
| Rate for Payer: Preferred Network Access Commercial |
$834.33
|
| Rate for Payer: Quartz Beloit One Network |
$444.37
|
| Rate for Payer: Quartz Commercial |
$589.47
|
| Rate for Payer: Quartz Medicare Advantage |
$544.13
|
| Rate for Payer: The Alliance Commercial |
$453.44
|
| Rate for Payer: WEA Trust Commercial |
$498.78
|
| Rate for Payer: WPS Commercial |
$671.70
|
|
|
PNEUMATIC WALK(M) SHORT 01-AM
|
Facility
|
IP
|
$872.00
|
|
| Hospital Charge Code |
2972439
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$444.37 |
| Max. Negotiated Rate |
$834.33 |
| Rate for Payer: Aetna Commercial |
$816.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$779.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$480.65
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$834.33
|
| Rate for Payer: Health EOS Commercial |
$807.12
|
| Rate for Payer: HFN Commercial |
$834.33
|
| Rate for Payer: Multiplan Commercial |
$725.50
|
| Rate for Payer: Preferred Network Access Commercial |
$834.33
|
| Rate for Payer: Quartz Beloit One Network |
$444.37
|
| Rate for Payer: Quartz Commercial |
$544.13
|
| Rate for Payer: WEA Trust Commercial |
$498.78
|
| Rate for Payer: WPS Commercial |
$671.70
|
|
|
PNEUMATIC WALK(S) SHORT 01A-S
|
Facility
|
OP
|
$872.00
|
|
| Hospital Charge Code |
2972377
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$253.93 |
| Max. Negotiated Rate |
$834.33 |
| Rate for Payer: Aetna Commercial |
$816.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$779.92
|
| Rate for Payer: Aetna Managed Medicare |
$253.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$589.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$453.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$435.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$480.65
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$834.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$507.50
|
| Rate for Payer: Health EOS Commercial |
$807.12
|
| Rate for Payer: HFN Commercial |
$834.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$680.16
|
| Rate for Payer: Multiplan Commercial |
$725.50
|
| Rate for Payer: NAPHCARE Commercial |
$544.13
|
| Rate for Payer: Preferred Network Access Commercial |
$834.33
|
| Rate for Payer: Quartz Beloit One Network |
$444.37
|
| Rate for Payer: Quartz Commercial |
$589.47
|
| Rate for Payer: Quartz Medicare Advantage |
$544.13
|
| Rate for Payer: The Alliance Commercial |
$453.44
|
| Rate for Payer: WEA Trust Commercial |
$498.78
|
| Rate for Payer: WPS Commercial |
$671.70
|
|
|
PNEUMATIC WALK(S) SHORT 01A-S
|
Facility
|
IP
|
$872.00
|
|
| Hospital Charge Code |
2972377
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$444.37 |
| Max. Negotiated Rate |
$834.33 |
| Rate for Payer: Aetna Commercial |
$816.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$779.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$480.65
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$834.33
|
| Rate for Payer: Health EOS Commercial |
$807.12
|
| Rate for Payer: HFN Commercial |
$834.33
|
| Rate for Payer: Multiplan Commercial |
$725.50
|
| Rate for Payer: Preferred Network Access Commercial |
$834.33
|
| Rate for Payer: Quartz Beloit One Network |
$444.37
|
| Rate for Payer: Quartz Commercial |
$544.13
|
| Rate for Payer: WEA Trust Commercial |
$498.78
|
| Rate for Payer: WPS Commercial |
$671.70
|
|
|
Pneuma/vac walk boot pre ots L4361
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
4498697
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$402.58 |
| Max. Negotiated Rate |
$755.87 |
| Rate for Payer: Aetna Commercial |
$739.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$706.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$435.45
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$755.87
|
| Rate for Payer: Health EOS Commercial |
$731.22
|
| Rate for Payer: HFN Commercial |
$755.87
|
| Rate for Payer: Multiplan Commercial |
$657.28
|
| Rate for Payer: Preferred Network Access Commercial |
$755.87
|
| Rate for Payer: Quartz Beloit One Network |
$402.58
|
| Rate for Payer: Quartz Commercial |
$492.96
|
| Rate for Payer: WEA Trust Commercial |
$451.88
|
| Rate for Payer: WPS Commercial |
$608.54
|
|
|
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 |
$159.21 |
| Max. Negotiated Rate |
$1,323.63 |
| Rate for Payer: Aetna Commercial |
$739.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$706.58
|
| Rate for Payer: Aetna Managed Medicare |
$230.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$159.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$159.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$435.45
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$755.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$459.78
|
| Rate for Payer: Health EOS Commercial |
$731.22
|
| Rate for Payer: HFN Commercial |
$755.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$616.20
|
| Rate for Payer: Multiplan Commercial |
$657.28
|
| Rate for Payer: NAPHCARE Commercial |
$492.96
|
| Rate for Payer: Preferred Network Access Commercial |
$755.87
|
| Rate for Payer: Quartz Beloit One Network |
$402.58
|
| Rate for Payer: Quartz Commercial |
$534.04
|
| Rate for Payer: Quartz Medicare Advantage |
$492.96
|
| Rate for Payer: The Alliance Commercial |
$1,323.63
|
| Rate for Payer: WEA Trust Commercial |
$451.88
|
| Rate for Payer: WPS Commercial |
$608.54
|
|
|
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 |
$330.91 |
| Max. Negotiated Rate |
$954.11 |
| Rate for Payer: Aetna Commercial |
$780.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$706.58
|
| Rate for Payer: Aetna Managed Medicare |
$330.91
|
| Rate for Payer: Anthem Medicare Advantage |
$330.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$330.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$330.91
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$780.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$410.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.91
|
| Rate for Payer: Health EOS Commercial |
$747.66
|
| Rate for Payer: HFN Commercial |
$780.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$954.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$954.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$330.91
|
| Rate for Payer: Multiplan Commercial |
$657.28
|
| Rate for Payer: NAPHCARE Commercial |
$496.36
|
| Rate for Payer: Preferred Network Access Commercial |
$780.52
|
| Rate for Payer: Quartz Beloit One Network |
$361.50
|
| Rate for Payer: Quartz Commercial |
$468.31
|
| Rate for Payer: Quartz Medicare Advantage |
$330.91
|
| Rate for Payer: The Alliance Commercial |
$909.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$330.91
|
| Rate for Payer: WEA Trust Commercial |
$451.88
|
| Rate for Payer: WPS Commercial |
$579.09
|
|
