|
Voyager 4.0mm x 8 mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Voyager 4.0mm x 8 mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
VRE Screen
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
979916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$83.98 |
| Rate for Payer: Aetna Commercial |
$83.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Aetna Managed Medicare |
$6.90
|
| Rate for Payer: Anthem Medicare Advantage |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.90
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$83.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.90
|
| Rate for Payer: Health EOS Commercial |
$80.44
|
| Rate for Payer: HFN Commercial |
$83.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.90
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: NAPHCARE Commercial |
$10.34
|
| Rate for Payer: Preferred Network Access Commercial |
$83.98
|
| Rate for Payer: Quartz Beloit One Network |
$38.90
|
| Rate for Payer: Quartz Commercial |
$50.39
|
| Rate for Payer: Quartz Medicare Advantage |
$6.90
|
| Rate for Payer: The Alliance Commercial |
$27.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.90
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$30.34
|
|
|
VRE Screen
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
979916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.32 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
VRE Screen
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
979916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Aetna Managed Medicare |
$6.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.07
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.45
|
| Rate for Payer: Anthem Medicare Advantage |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.90
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.90
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.90
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: NAPHCARE Commercial |
$10.34
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$57.46
|
| Rate for Payer: Quartz Medicare Advantage |
$6.90
|
| Rate for Payer: The Alliance Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.90
|
| Rate for Payer: United Healthcare PPO |
$66.30
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: Wellcare Medicare |
$6.90
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
VULVAPLASTY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960507
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
VULVAPLASTY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960507
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Facility
|
OP
|
$13,626.87
|
|
|
Service Code
|
CPT 56620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,835.04 |
| Max. Negotiated Rate |
$13,626.87 |
| Rate for Payer: Aetna Managed Medicare |
$3,406.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$3,406.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,406.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,406.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,406.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,673.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,406.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,672.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,406.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,406.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,406.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,406.72
|
| Rate for Payer: NAPHCARE Commercial |
$5,110.08
|
| Rate for Payer: Quartz Medicare Advantage |
$3,406.72
|
| Rate for Payer: The Alliance Commercial |
$13,626.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,406.72
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$3,406.72
|
|
|
VZV, Rapid Cx / 2691
|
Professional
|
Both
|
$383.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
5773623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.34 |
| Max. Negotiated Rate |
$378.40 |
| Rate for Payer: Aetna Commercial |
$378.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.56
|
| Rate for Payer: Aetna Managed Medicare |
$20.34
|
| Rate for Payer: Anthem Medicare Advantage |
$20.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.34
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$378.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$199.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.34
|
| Rate for Payer: Health EOS Commercial |
$362.47
|
| Rate for Payer: HFN Commercial |
$378.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$71.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.34
|
| Rate for Payer: Multiplan Commercial |
$318.66
|
| Rate for Payer: NAPHCARE Commercial |
$30.51
|
| Rate for Payer: Preferred Network Access Commercial |
$378.40
|
| Rate for Payer: Quartz Beloit One Network |
$175.26
|
| Rate for Payer: Quartz Commercial |
$227.04
|
| Rate for Payer: Quartz Medicare Advantage |
$20.34
|
| Rate for Payer: The Alliance Commercial |
$80.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.34
|
| Rate for Payer: WEA Trust Commercial |
$219.08
|
| Rate for Payer: WPS Commercial |
$89.51
|
|
|
VZV, Rapid Cx / 2691
|
Facility
|
OP
|
$383.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
5773623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.34 |
| Max. Negotiated Rate |
$366.45 |
| Rate for Payer: Aetna Commercial |
$358.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.56
|
| Rate for Payer: Aetna Managed Medicare |
$20.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$76.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.77
|
| Rate for Payer: Anthem Medicare Advantage |
$20.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$211.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.34
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$366.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.34
|
| Rate for Payer: Health EOS Commercial |
$354.50
|
| Rate for Payer: HFN Commercial |
$366.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.34
|
| Rate for Payer: Multiplan Commercial |
$318.66
|
| Rate for Payer: NAPHCARE Commercial |
$30.51
|
| Rate for Payer: Preferred Network Access Commercial |
$366.45
|
| Rate for Payer: Quartz Beloit One Network |
$195.18
|
| Rate for Payer: Quartz Commercial |
$258.91
|
| Rate for Payer: Quartz Medicare Advantage |
$20.34
|
| Rate for Payer: The Alliance Commercial |
$81.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.34
|
| Rate for Payer: United Healthcare PPO |
$298.74
|
| Rate for Payer: WEA Trust Commercial |
$219.08
|
| Rate for Payer: Wellcare Medicare |
$20.34
|
| Rate for Payer: WPS Commercial |
$295.02
|
|
|
VZV, Rapid Cx / 2691
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
5773623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$195.18 |
| Max. Negotiated Rate |
$366.45 |
| Rate for Payer: Aetna Commercial |
$358.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$211.11
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$366.45
|
| Rate for Payer: Health EOS Commercial |
$354.50
|
| Rate for Payer: HFN Commercial |
$366.45
|
| Rate for Payer: Multiplan Commercial |
$318.66
|
| Rate for Payer: Preferred Network Access Commercial |
$366.45
|
| Rate for Payer: Quartz Beloit One Network |
$195.18
|
| Rate for Payer: Quartz Commercial |
$238.99
|
| Rate for Payer: WEA Trust Commercial |
$219.08
|
| Rate for Payer: WPS Commercial |
$295.02
|
|
|
WA1 IgG Antibody, IFA
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
5355236
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.89 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$12.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.55
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.39
|
| Rate for Payer: Anthem Medicare Advantage |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.89
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.89
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.89
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.89
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$19.33
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$12.89
|
| Rate for Payer: The Alliance Commercial |
$51.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.89
|
| Rate for Payer: United Healthcare PPO |
$117.78
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: Wellcare Medicare |
$12.89
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
WA1 IgG Antibody, IFA
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
5355236
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
WA1 IgG Antibody, IFA
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
5355236
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.89 |
| Max. Negotiated Rate |
$149.19 |
| Rate for Payer: Aetna Commercial |
$149.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$12.89
|
| Rate for Payer: Anthem Medicare Advantage |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.89
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$149.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.89
|
| Rate for Payer: Health EOS Commercial |
$142.91
|
| Rate for Payer: HFN Commercial |
$149.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.89
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$19.33
|
| Rate for Payer: Preferred Network Access Commercial |
$149.19
|
| Rate for Payer: Quartz Beloit One Network |
$69.10
|
| Rate for Payer: Quartz Commercial |
$89.51
|
| Rate for Payer: Quartz Medicare Advantage |
$12.89
|
| Rate for Payer: The Alliance Commercial |
$50.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.89
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$56.70
|
|
|
WAIS IV RECORD FORM
|
Facility
|
IP
|
$1,754.00
|
|
| Hospital Charge Code |
2972682
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$893.84 |
| Max. Negotiated Rate |
$1,678.23 |
| Rate for Payer: Aetna Commercial |
$1,641.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,568.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$966.80
|
| Rate for Payer: Cash Price |
$526.20
|
| Rate for Payer: Cigna Commercial |
$1,678.23
|
| Rate for Payer: Health EOS Commercial |
$1,623.50
|
| Rate for Payer: HFN Commercial |
$1,678.23
|
| Rate for Payer: Multiplan Commercial |
$1,459.33
|
| Rate for Payer: Preferred Network Access Commercial |
$1,678.23
|
| Rate for Payer: Quartz Beloit One Network |
$893.84
|
| Rate for Payer: Quartz Commercial |
$1,094.50
|
| Rate for Payer: WEA Trust Commercial |
$1,003.29
|
| Rate for Payer: WPS Commercial |
$1,351.11
|
|
|
WAIS IV RECORD FORM
|
Facility
|
OP
|
$1,754.00
|
|
| Hospital Charge Code |
2972682
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$510.76 |
| Max. Negotiated Rate |
$1,678.23 |
| Rate for Payer: Aetna Commercial |
$1,641.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,568.78
|
| Rate for Payer: Aetna Managed Medicare |
$510.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,185.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$912.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$875.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$966.80
|
| Rate for Payer: Cash Price |
$526.20
|
| Rate for Payer: Cigna Commercial |
$1,678.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,020.83
|
| Rate for Payer: Health EOS Commercial |
$1,623.50
|
| Rate for Payer: HFN Commercial |
$1,678.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,368.12
|
| Rate for Payer: Multiplan Commercial |
$1,459.33
|
| Rate for Payer: NAPHCARE Commercial |
$1,094.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,678.23
|
| Rate for Payer: Quartz Beloit One Network |
$893.84
|
| Rate for Payer: Quartz Commercial |
$1,185.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,094.50
|
| Rate for Payer: The Alliance Commercial |
$912.08
|
| Rate for Payer: WEA Trust Commercial |
$1,003.29
|
| Rate for Payer: WPS Commercial |
$1,351.11
|
|
|
WAIS IV RESPONSE BOOKLET 2
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
2971755
|
|
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
|
|
|
WAIS IV RESPONSE BOOKLET 2
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
2971755
|
|
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
|
|
|
WALKER CAM #L4360
|
Facility
|
OP
|
$3,075.00
|
|
| Hospital Charge Code |
2974046
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$2,942.16 |
| Rate for Payer: Aetna Commercial |
$2,878.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,750.28
|
| Rate for Payer: Aetna Managed Medicare |
$895.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,078.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,599.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,535.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.94
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Cigna Commercial |
$2,942.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,789.65
|
| Rate for Payer: Health EOS Commercial |
$2,846.22
|
| Rate for Payer: HFN Commercial |
$2,942.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,398.50
|
| Rate for Payer: Multiplan Commercial |
$2,558.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,942.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,567.02
|
| Rate for Payer: Quartz Commercial |
$2,078.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,918.80
|
| Rate for Payer: The Alliance Commercial |
$1,599.00
|
| Rate for Payer: WEA Trust Commercial |
$1,758.90
|
| Rate for Payer: WPS Commercial |
$2,368.67
|
|
|
WALKER CAM #L4360
|
Facility
|
IP
|
$3,075.00
|
|
| Hospital Charge Code |
2974046
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,567.02 |
| Max. Negotiated Rate |
$2,942.16 |
| Rate for Payer: Aetna Commercial |
$2,878.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,750.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.94
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Cigna Commercial |
$2,942.16
|
| Rate for Payer: Health EOS Commercial |
$2,846.22
|
| Rate for Payer: HFN Commercial |
$2,942.16
|
| Rate for Payer: Multiplan Commercial |
$2,558.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,942.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,567.02
|
| Rate for Payer: Quartz Commercial |
$1,918.80
|
| Rate for Payer: WEA Trust Commercial |
$1,758.90
|
| Rate for Payer: WPS Commercial |
$2,368.67
|
|
|
WALKER,INLINE AIR,CLOSED HEEL,M 15490006
|
Facility
|
IP
|
$1,000.00
|
|
| Hospital Charge Code |
2974607
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$509.60 |
| Max. Negotiated Rate |
$956.80 |
| Rate for Payer: Aetna Commercial |
$936.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$894.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$551.20
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$956.80
|
| Rate for Payer: Health EOS Commercial |
$925.60
|
| Rate for Payer: HFN Commercial |
$956.80
|
| Rate for Payer: Multiplan Commercial |
$832.00
|
| Rate for Payer: Preferred Network Access Commercial |
$956.80
|
| Rate for Payer: Quartz Beloit One Network |
$509.60
|
| Rate for Payer: Quartz Commercial |
$624.00
|
| Rate for Payer: WEA Trust Commercial |
$572.00
|
| Rate for Payer: WPS Commercial |
$770.30
|
|
|
WALKER,INLINE AIR,CLOSED HEEL,M 15490006
|
Facility
|
OP
|
$1,000.00
|
|
| Hospital Charge Code |
2974607
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$291.20 |
| Max. Negotiated Rate |
$956.80 |
| Rate for Payer: Aetna Commercial |
$936.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$894.40
|
| Rate for Payer: Aetna Managed Medicare |
$291.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$676.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$520.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$499.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$551.20
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$956.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$582.00
|
| Rate for Payer: Health EOS Commercial |
$925.60
|
| Rate for Payer: HFN Commercial |
$956.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$780.00
|
| Rate for Payer: Multiplan Commercial |
$832.00
|
| Rate for Payer: NAPHCARE Commercial |
$624.00
|
| Rate for Payer: Preferred Network Access Commercial |
$956.80
|
| Rate for Payer: Quartz Beloit One Network |
$509.60
|
| Rate for Payer: Quartz Commercial |
$676.00
|
| Rate for Payer: Quartz Medicare Advantage |
$624.00
|
| Rate for Payer: The Alliance Commercial |
$520.00
|
| Rate for Payer: WEA Trust Commercial |
$572.00
|
| Rate for Payer: WPS Commercial |
$770.30
|
|
|
WALKER INLINE OPEN HEEL SMALL
|
Facility
|
IP
|
$999.00
|
|
| Hospital Charge Code |
2974606
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$509.09 |
| Max. Negotiated Rate |
$955.84 |
| Rate for Payer: Aetna Commercial |
$935.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$893.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$550.65
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cigna Commercial |
$955.84
|
| Rate for Payer: Health EOS Commercial |
$924.67
|
| Rate for Payer: HFN Commercial |
$955.84
|
| Rate for Payer: Multiplan Commercial |
$831.17
|
| Rate for Payer: Preferred Network Access Commercial |
$955.84
|
| Rate for Payer: Quartz Beloit One Network |
$509.09
|
| Rate for Payer: Quartz Commercial |
$623.38
|
| Rate for Payer: WEA Trust Commercial |
$571.43
|
| Rate for Payer: WPS Commercial |
$769.53
|
|
|
WALKER INLINE OPEN HEEL SMALL
|
Facility
|
OP
|
$999.00
|
|
| Hospital Charge Code |
2974606
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$290.91 |
| Max. Negotiated Rate |
$955.84 |
| Rate for Payer: Aetna Commercial |
$935.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$893.51
|
| Rate for Payer: Aetna Managed Medicare |
$290.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$675.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$519.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$498.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$550.65
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cigna Commercial |
$955.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$581.42
|
| Rate for Payer: Health EOS Commercial |
$924.67
|
| Rate for Payer: HFN Commercial |
$955.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$779.22
|
| Rate for Payer: Multiplan Commercial |
$831.17
|
| Rate for Payer: NAPHCARE Commercial |
$623.38
|
| Rate for Payer: Preferred Network Access Commercial |
$955.84
|
| Rate for Payer: Quartz Beloit One Network |
$509.09
|
| Rate for Payer: Quartz Commercial |
$675.32
|
| Rate for Payer: Quartz Medicare Advantage |
$623.38
|
| Rate for Payer: The Alliance Commercial |
$519.48
|
| Rate for Payer: WEA Trust Commercial |
$571.43
|
| Rate for Payer: WPS Commercial |
$769.53
|
|
|
WALKER PNEUMANTIC AIR SMALL 15490005
|
Facility
|
IP
|
$1,000.00
|
|
| Hospital Charge Code |
2974605
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$509.60 |
| Max. Negotiated Rate |
$956.80 |
| Rate for Payer: Aetna Commercial |
$936.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$894.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$551.20
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$956.80
|
| Rate for Payer: Health EOS Commercial |
$925.60
|
| Rate for Payer: HFN Commercial |
$956.80
|
| Rate for Payer: Multiplan Commercial |
$832.00
|
| Rate for Payer: Preferred Network Access Commercial |
$956.80
|
| Rate for Payer: Quartz Beloit One Network |
$509.60
|
| Rate for Payer: Quartz Commercial |
$624.00
|
| Rate for Payer: WEA Trust Commercial |
$572.00
|
| Rate for Payer: WPS Commercial |
$770.30
|
|
