|
UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM
|
Facility
|
OP
|
$27,974.00
|
|
|
Service Code
|
CPT 22999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$233.09 |
| Max. Negotiated Rate |
$27,974.00 |
| Rate for Payer: Aetna Managed Medicare |
$233.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,974.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,272.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,008.00
|
| Rate for Payer: Anthem Medicare Advantage |
$233.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$233.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$233.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$233.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$233.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$867.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$233.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$233.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$233.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$233.09
|
| Rate for Payer: NAPHCARE Commercial |
$349.64
|
| Rate for Payer: Quartz Medicare Advantage |
$233.09
|
| Rate for Payer: The Alliance Commercial |
$932.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$233.09
|
| Rate for Payer: United Healthcare PPO |
$13,676.00
|
| Rate for Payer: Wellcare Medicare |
$233.09
|
|
|
UNLISTED PROCEDURE, ANUS
|
Facility
|
OP
|
$27,974.00
|
|
|
Service Code
|
CPT 46999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$903.36 |
| Max. Negotiated Rate |
$27,974.00 |
| Rate for Payer: Aetna Managed Medicare |
$903.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,974.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,272.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,008.00
|
| Rate for Payer: Anthem Medicare Advantage |
$903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$903.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$903.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$903.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,360.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$903.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$903.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$903.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$903.36
|
| Rate for Payer: NAPHCARE Commercial |
$1,355.04
|
| Rate for Payer: Quartz Medicare Advantage |
$903.36
|
| Rate for Payer: The Alliance Commercial |
$3,613.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$903.36
|
| Rate for Payer: United Healthcare PPO |
$13,676.00
|
| Rate for Payer: Wellcare Medicare |
$903.36
|
|
|
UNLISTED PROCEDURE, ARTHROSCOPY
|
Facility
|
OP
|
$27,974.00
|
|
|
Service Code
|
CPT 29999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$233.09 |
| Max. Negotiated Rate |
$27,974.00 |
| Rate for Payer: Aetna Managed Medicare |
$233.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,974.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,272.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,008.00
|
| Rate for Payer: Anthem Medicare Advantage |
$233.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$233.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$233.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$233.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$233.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$867.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$233.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$233.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$233.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$233.09
|
| Rate for Payer: NAPHCARE Commercial |
$349.64
|
| Rate for Payer: Quartz Medicare Advantage |
$233.09
|
| Rate for Payer: The Alliance Commercial |
$932.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$233.09
|
| Rate for Payer: United Healthcare PPO |
$13,676.00
|
| Rate for Payer: Wellcare Medicare |
$233.09
|
|
|
UNLISTED PROCEDURE, LEG OR ANKLE
|
Facility
|
OP
|
$27,974.00
|
|
|
Service Code
|
CPT 27899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$233.09 |
| Max. Negotiated Rate |
$27,974.00 |
| Rate for Payer: Aetna Managed Medicare |
$233.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,974.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,272.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,008.00
|
| Rate for Payer: Anthem Medicare Advantage |
$233.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$233.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$233.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$233.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$233.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$867.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$233.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$233.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$233.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$233.09
|
| Rate for Payer: NAPHCARE Commercial |
$349.64
|
| Rate for Payer: Quartz Medicare Advantage |
$233.09
|
| Rate for Payer: The Alliance Commercial |
$932.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$233.09
|
| Rate for Payer: United Healthcare PPO |
$13,676.00
|
| Rate for Payer: Wellcare Medicare |
$233.09
|
|
|
UNLISTED PROCEDURE, PHARYNX, ADENOIDS, OR TONSILS
|
Facility
|
OP
|
$27,974.00
|
|
|
Service Code
|
CPT 42999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$241.43 |
| Max. Negotiated Rate |
$27,974.00 |
| Rate for Payer: Aetna Managed Medicare |
$241.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,974.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,272.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,008.00
|
| Rate for Payer: Anthem Medicare Advantage |
$241.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$241.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$241.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$241.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$241.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$898.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$241.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$241.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$241.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$241.43
|
| Rate for Payer: NAPHCARE Commercial |
$362.14
|
| Rate for Payer: Quartz Medicare Advantage |
$241.43
|
| Rate for Payer: The Alliance Commercial |
$965.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$241.43
|
| Rate for Payer: United Healthcare PPO |
$13,676.00
|
| Rate for Payer: Wellcare Medicare |
$241.43
|
|
|
UNLISTED PROCEDURE STOMACH 43999-43762
|
Professional
|
Both
|
$204.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
5609741
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$89.76 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Aetna Commercial |
$193.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.44
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$193.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.40
|
| Rate for Payer: Health EOS Commercial |
$185.64
|
| Rate for Payer: HFN Commercial |
$193.80
|
| Rate for Payer: Multiplan Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$193.80
|
| Rate for Payer: Quartz Beloit One Network |
$89.76
|
| Rate for Payer: Quartz Commercial |
$116.28
|
| Rate for Payer: The Alliance Commercial |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$112.20
|
| Rate for Payer: WPS Commercial |
$151.10
|
|
|
UNLISTED PROCEDURE, VASCULAR SURGERY
|
Facility
|
OP
|
$27,974.00
|
|
|
Service Code
|
CPT 37799
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$620.92 |
| Max. Negotiated Rate |
$27,974.00 |
| Rate for Payer: Aetna Managed Medicare |
$620.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,974.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,272.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,008.00
|
| Rate for Payer: Anthem Medicare Advantage |
$620.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$620.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$620.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$620.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$620.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,309.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$620.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$620.92
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$620.92
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$620.92
|
| Rate for Payer: NAPHCARE Commercial |
$931.38
|
| Rate for Payer: Quartz Medicare Advantage |
$620.92
|
| Rate for Payer: The Alliance Commercial |
$2,483.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$620.92
|
| Rate for Payer: United Healthcare PPO |
$13,676.00
|
| Rate for Payer: Wellcare Medicare |
$620.92
|
|
|
Unna Boot
|
Professional
|
Both
|
$182.00
|
|
|
Service Code
|
CPT 29580
|
| Hospital Charge Code |
2572822
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.21 |
| Max. Negotiated Rate |
$172.90 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.20
|
| Rate for Payer: Health EOS Commercial |
$165.62
|
| Rate for Payer: HFN Commercial |
$172.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.50
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$172.90
|
| Rate for Payer: Quartz Beloit One Network |
$80.08
|
| Rate for Payer: Quartz Commercial |
$103.74
|
| Rate for Payer: The Alliance Commercial |
$91.00
|
| Rate for Payer: United Healthcare Medicaid |
$20.21
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.81
|
|
|
Unna Boot 29580PP
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
CPT 29580
|
| Hospital Charge Code |
3133515
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.21 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna Commercial |
$285.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$285.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.00
|
| Rate for Payer: Health EOS Commercial |
$273.00
|
| Rate for Payer: HFN Commercial |
$285.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.50
|
| Rate for Payer: Multiplan Commercial |
$240.00
|
| Rate for Payer: Preferred Network Access Commercial |
$285.00
|
| Rate for Payer: Quartz Beloit One Network |
$132.00
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$150.00
|
| Rate for Payer: United Healthcare Medicaid |
$20.21
|
| Rate for Payer: WEA Trust Commercial |
$165.00
|
| Rate for Payer: WPS Commercial |
$222.21
|
|
|
Unscheduled dialysis for an ESRD patient
|
Facility
|
IP
|
$1,331.00
|
|
|
Service Code
|
HCPCS G0257
|
| Hospital Charge Code |
5164612
|
|
Hospital Revenue Code
|
821
|
| Min. Negotiated Rate |
$652.19 |
| Max. Negotiated Rate |
$1,224.52 |
| Rate for Payer: Aetna Commercial |
$1,197.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,144.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$705.43
|
| Rate for Payer: Cash Price |
$399.30
|
| Rate for Payer: Cigna Commercial |
$1,224.52
|
| Rate for Payer: Health EOS Commercial |
$1,184.59
|
| Rate for Payer: HFN Commercial |
$1,224.52
|
| Rate for Payer: Multiplan Commercial |
$1,064.80
|
| Rate for Payer: NAPHCARE Commercial |
$798.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,224.52
|
| Rate for Payer: Quartz Beloit One Network |
$652.19
|
| Rate for Payer: Quartz Commercial |
$798.60
|
| Rate for Payer: WEA Trust Commercial |
$732.05
|
| Rate for Payer: WPS Commercial |
$985.87
|
|
|
Unscheduled dialysis for an ESRD patient
|
Facility
|
OP
|
$1,331.00
|
|
|
Service Code
|
HCPCS G0257
|
| Hospital Charge Code |
5164612
|
|
Hospital Revenue Code
|
821
|
| Min. Negotiated Rate |
$652.19 |
| Max. Negotiated Rate |
$2,762.80 |
| Rate for Payer: Aetna Commercial |
$1,197.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,144.66
|
| Rate for Payer: Aetna Managed Medicare |
$690.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,281.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,091.00
|
| Rate for Payer: Anthem Medicare Advantage |
$690.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$705.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$690.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$690.70
|
| Rate for Payer: Cash Price |
$399.30
|
| Rate for Payer: Cash Price |
$399.30
|
| Rate for Payer: Cash Price |
$399.30
|
| Rate for Payer: Cigna Commercial |
$1,224.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$690.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$744.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$690.70
|
| Rate for Payer: Health EOS Commercial |
$1,184.59
|
| Rate for Payer: HFN Commercial |
$1,224.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,569.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$690.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$690.70
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$690.70
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$690.70
|
| Rate for Payer: Multiplan Commercial |
$1,064.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,036.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,224.52
|
| Rate for Payer: Quartz Beloit One Network |
$652.19
|
| Rate for Payer: Quartz Commercial |
$865.15
|
| Rate for Payer: Quartz Medicare Advantage |
$690.70
|
| Rate for Payer: The Alliance Commercial |
$2,762.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$690.70
|
| Rate for Payer: United Healthcare PPO |
$998.25
|
| Rate for Payer: WEA Trust Commercial |
$732.05
|
| Rate for Payer: Wellcare Medicare |
$690.70
|
| Rate for Payer: WPS Commercial |
$985.87
|
|
|
UPEP Interpretation
|
Professional
|
Both
|
$237.00
|
|
|
Service Code
|
CPT 84166
|
| Hospital Charge Code |
2942979
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.41 |
| Max. Negotiated Rate |
$225.15 |
| Rate for Payer: Aetna Commercial |
$225.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Anthem Commercial |
$19.41
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$225.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$118.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.20
|
| Rate for Payer: Health EOS Commercial |
$215.67
|
| Rate for Payer: HFN Commercial |
$225.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.94
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: Preferred Network Access Commercial |
$225.15
|
| Rate for Payer: Quartz Beloit One Network |
$104.28
|
| Rate for Payer: Quartz Commercial |
$135.09
|
| Rate for Payer: The Alliance Commercial |
$118.50
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
|
UPEP Interpretation
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
CPT 84166
|
| Hospital Charge Code |
2942979
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.13 |
| Max. Negotiated Rate |
$218.04 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.61
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$218.04
|
| Rate for Payer: Health EOS Commercial |
$210.93
|
| Rate for Payer: HFN Commercial |
$218.04
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: NAPHCARE Commercial |
$142.20
|
| Rate for Payer: Preferred Network Access Commercial |
$218.04
|
| Rate for Payer: Quartz Beloit One Network |
$116.13
|
| Rate for Payer: Quartz Commercial |
$142.20
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
|
UPEP Interpretation
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
CPT 84166
|
| Hospital Charge Code |
2942979
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.83 |
| Max. Negotiated Rate |
$218.04 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Aetna Managed Medicare |
$17.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.60
|
| Rate for Payer: Anthem Medicaid |
$18.42
|
| Rate for Payer: Anthem Medicare Advantage |
$17.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.83
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$218.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.63
|
| Rate for Payer: Dean Health Medicaid |
$18.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.83
|
| Rate for Payer: Health EOS Commercial |
$210.93
|
| Rate for Payer: HFN Commercial |
$218.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.83
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.83
|
| Rate for Payer: Managed Health Services Medicaid |
$19.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.83
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.83
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: NAPHCARE Commercial |
$26.74
|
| Rate for Payer: Preferred Network Access Commercial |
$218.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.42
|
| Rate for Payer: Quartz Beloit One Network |
$116.13
|
| Rate for Payer: Quartz Commercial |
$154.05
|
| Rate for Payer: Quartz Medicare Advantage |
$17.83
|
| Rate for Payer: The Alliance Commercial |
$71.32
|
| Rate for Payer: United Healthcare Medicaid |
$18.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.83
|
| Rate for Payer: United Healthcare PPO |
$177.75
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: Wellcare Medicare |
$17.83
|
| Rate for Payer: WMAP Medicaid |
$18.42
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
|
U Porphyrins, Fract, Qnt / 36592
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
3423526
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$109.48 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Aetna Managed Medicare |
$14.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.42
|
| Rate for Payer: Anthem Medicaid |
$15.20
|
| Rate for Payer: Anthem Medicare Advantage |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.71
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$109.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.59
|
| Rate for Payer: Dean Health Medicaid |
$15.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.71
|
| Rate for Payer: Health EOS Commercial |
$105.91
|
| Rate for Payer: HFN Commercial |
$109.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.71
|
| Rate for Payer: Managed Health Services Medicaid |
$15.81
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.71
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.06
|
| Rate for Payer: Preferred Network Access Commercial |
$109.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.20
|
| Rate for Payer: Quartz Beloit One Network |
$58.31
|
| Rate for Payer: Quartz Commercial |
$77.35
|
| Rate for Payer: Quartz Medicare Advantage |
$14.71
|
| Rate for Payer: The Alliance Commercial |
$58.84
|
| Rate for Payer: United Healthcare Medicaid |
$15.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.71
|
| Rate for Payer: United Healthcare PPO |
$89.25
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: Wellcare Medicare |
$14.71
|
| Rate for Payer: WMAP Medicaid |
$15.20
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
U Porphyrins, Fract, Qnt / 36592
|
Professional
|
Both
|
$119.00
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
3423526
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.93 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Aetna Commercial |
$113.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.40
|
| Rate for Payer: Health EOS Commercial |
$108.29
|
| Rate for Payer: HFN Commercial |
$113.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.93
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: Preferred Network Access Commercial |
$113.05
|
| Rate for Payer: Quartz Beloit One Network |
$52.36
|
| Rate for Payer: Quartz Commercial |
$67.83
|
| Rate for Payer: The Alliance Commercial |
$59.50
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
U Porphyrins, Fract, Qnt / 36592
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
3423526
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$109.48 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.07
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$109.48
|
| Rate for Payer: Health EOS Commercial |
$105.91
|
| Rate for Payer: HFN Commercial |
$109.48
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: NAPHCARE Commercial |
$71.40
|
| Rate for Payer: Preferred Network Access Commercial |
$109.48
|
| Rate for Payer: Quartz Beloit One Network |
$58.31
|
| Rate for Payer: Quartz Commercial |
$71.40
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
U-POUCH FLUID COLLECTION STERI-DRAPE 3M 1067
|
Facility
|
IP
|
$107.00
|
|
| Hospital Charge Code |
2963482
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$98.44 |
| Rate for Payer: Aetna Commercial |
$96.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.71
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$98.44
|
| Rate for Payer: Health EOS Commercial |
$95.23
|
| Rate for Payer: HFN Commercial |
$98.44
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: NAPHCARE Commercial |
$64.20
|
| Rate for Payer: Preferred Network Access Commercial |
$98.44
|
| Rate for Payer: Quartz Beloit One Network |
$52.43
|
| Rate for Payer: Quartz Commercial |
$64.20
|
| Rate for Payer: WEA Trust Commercial |
$58.85
|
| Rate for Payer: WPS Commercial |
$79.25
|
|
|
U-POUCH FLUID COLLECTION STERI-DRAPE 3M 1067
|
Facility
|
OP
|
$107.00
|
|
| Hospital Charge Code |
2963482
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.96 |
| Max. Negotiated Rate |
$428.00 |
| Rate for Payer: Aetna Commercial |
$96.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.02
|
| Rate for Payer: Aetna Managed Medicare |
$29.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.71
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$98.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.88
|
| Rate for Payer: Health EOS Commercial |
$95.23
|
| Rate for Payer: HFN Commercial |
$98.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.25
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: NAPHCARE Commercial |
$64.20
|
| Rate for Payer: Preferred Network Access Commercial |
$98.44
|
| Rate for Payer: Quartz Beloit One Network |
$52.43
|
| Rate for Payer: Quartz Commercial |
$69.55
|
| Rate for Payer: Quartz Medicare Advantage |
$64.20
|
| Rate for Payer: The Alliance Commercial |
$428.00
|
| Rate for Payer: WEA Trust Commercial |
$58.85
|
| Rate for Payer: WPS Commercial |
$79.25
|
|
|
UPPER GI ENDOSCOPY, BIOPSY 43239
|
Professional
|
Both
|
$1,747.00
|
|
|
Service Code
|
CPT 43239
|
| Hospital Charge Code |
3014656
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$301.74 |
| Max. Negotiated Rate |
$1,659.65 |
| Rate for Payer: Aetna Commercial |
$1,659.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,502.42
|
| Rate for Payer: Cash Price |
$524.10
|
| Rate for Payer: Cash Price |
$524.10
|
| Rate for Payer: Cigna Commercial |
$1,659.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$301.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,048.20
|
| Rate for Payer: Health EOS Commercial |
$1,589.77
|
| Rate for Payer: HFN Commercial |
$1,659.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$462.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$462.82
|
| Rate for Payer: Multiplan Commercial |
$1,397.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,659.65
|
| Rate for Payer: Quartz Beloit One Network |
$768.68
|
| Rate for Payer: Quartz Commercial |
$995.79
|
| Rate for Payer: The Alliance Commercial |
$873.50
|
| Rate for Payer: United Healthcare Medicaid |
$301.74
|
| Rate for Payer: WEA Trust Commercial |
$960.85
|
| Rate for Payer: WPS Commercial |
$1,294.00
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC
|
Facility
|
IP
|
$43,913.00
|
|
|
Service Code
|
MSDRG 256
|
| Min. Negotiated Rate |
$15,796.20 |
| Max. Negotiated Rate |
$43,913.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,796.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,407.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,372.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,055.92
|
| Rate for Payer: Anthem Medicare Advantage |
$15,796.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,796.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,796.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,796.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,814.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,796.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,974.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,796.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,796.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,796.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,796.20
|
| Rate for Payer: NAPHCARE Commercial |
$23,694.30
|
| Rate for Payer: Quartz Medicare Advantage |
$15,796.20
|
| Rate for Payer: The Alliance Commercial |
$43,913.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,796.20
|
| Rate for Payer: United Healthcare PPO |
$24,892.29
|
| Rate for Payer: Wellcare Medicare |
$15,796.20
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC
|
Facility
|
IP
|
$73,363.00
|
|
|
Service Code
|
MSDRG 255
|
| Min. Negotiated Rate |
$26,389.48 |
| Max. Negotiated Rate |
$73,363.00 |
| Rate for Payer: Aetna Managed Medicare |
$26,389.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57,695.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44,222.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42,014.50
|
| Rate for Payer: Anthem Medicare Advantage |
$26,389.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26,389.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26,389.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$26,389.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46,639.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$26,389.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53,574.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$26,389.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26,389.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$26,389.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$26,389.48
|
| Rate for Payer: NAPHCARE Commercial |
$39,584.22
|
| Rate for Payer: Quartz Medicare Advantage |
$26,389.48
|
| Rate for Payer: The Alliance Commercial |
$73,363.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26,389.48
|
| Rate for Payer: United Healthcare PPO |
$41,708.28
|
| Rate for Payer: Wellcare Medicare |
$26,389.48
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$26,667.00
|
|
|
Service Code
|
MSDRG 257
|
| Min. Negotiated Rate |
$9,592.50 |
| Max. Negotiated Rate |
$26,667.00 |
| Rate for Payer: Aetna Managed Medicare |
$9,592.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,770.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,920.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,125.22
|
| Rate for Payer: Anthem Medicare Advantage |
$9,592.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,592.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,592.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,592.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16,790.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,592.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,324.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,592.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,592.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,592.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,592.50
|
| Rate for Payer: NAPHCARE Commercial |
$14,388.75
|
| Rate for Payer: Quartz Medicare Advantage |
$9,592.50
|
| Rate for Payer: The Alliance Commercial |
$26,667.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,592.50
|
| Rate for Payer: United Healthcare PPO |
$15,044.37
|
| Rate for Payer: Wellcare Medicare |
$9,592.50
|
|
|
Upper limb orthosis NOS L3999
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
HCPCS L3999
|
| Hospital Charge Code |
3165660
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$159.04 |
| Max. Negotiated Rate |
$2,272.00 |
| Rate for Payer: Aetna Commercial |
$511.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Aetna Managed Medicare |
$159.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$284.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.04
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$522.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$317.85
|
| Rate for Payer: Health EOS Commercial |
$505.52
|
| Rate for Payer: HFN Commercial |
$522.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.00
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: NAPHCARE Commercial |
$340.80
|
| Rate for Payer: Preferred Network Access Commercial |
$522.56
|
| Rate for Payer: Quartz Beloit One Network |
$278.32
|
| Rate for Payer: Quartz Commercial |
$369.20
|
| Rate for Payer: Quartz Medicare Advantage |
$340.80
|
| Rate for Payer: The Alliance Commercial |
$2,272.00
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
Upper limb orthosis NOS L3999
|
Professional
|
Both
|
$568.00
|
|
|
Service Code
|
HCPCS L3999
|
| Hospital Charge Code |
3165660
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$249.92 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Aetna Commercial |
$539.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$539.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$284.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$340.80
|
| Rate for Payer: Health EOS Commercial |
$516.88
|
| Rate for Payer: HFN Commercial |
$539.60
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: Preferred Network Access Commercial |
$539.60
|
| Rate for Payer: Quartz Beloit One Network |
$249.92
|
| Rate for Payer: Quartz Commercial |
$323.76
|
| Rate for Payer: The Alliance Commercial |
$284.00
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
