|
Acetylcholine Receptor Blocking Antibody
|
Facility
OP
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.72
|
| Rate for Payer: Dean Health Medicaid |
$14.72
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.72
|
| Rate for Payer: Managed Health Services Medicaid |
$15.31
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.72
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$96.00
|
| Rate for Payer: The Alliance Commercial |
$640.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.72
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WMAP Medicaid |
$14.72
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Professional
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.00
|
| Rate for Payer: Health EOS Commercial |
$145.60
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$152.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.40
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Facility
OP
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$9.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.64
|
| Rate for Payer: Dean Health Medicaid |
$9.64
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.64
|
| Rate for Payer: Managed Health Services Medicaid |
$10.03
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.64
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$96.00
|
| Rate for Payer: The Alliance Commercial |
$640.00
|
| Rate for Payer: United Healthcare Medicaid |
$9.64
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WMAP Medicaid |
$9.64
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Facility
IP
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
acetylcysteine for esophageal ablation [Med]
|
Facility
OP
|
$115.00
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2983114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$3,277.16 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$32.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.02
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.25
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$69.00
|
| Rate for Payer: The Alliance Commercial |
$3,277.16
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
acetylcysteine for esophageal ablation [Med]
|
Facility
IP
|
$115.00
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2983114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
Ace wrap applied, 3 in - Treatments Done
|
Facility
IP
|
$56.00
|
|
| Hospital Charge Code |
3002566
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Ace wrap applied, 3 in - Treatments Done
|
Facility
OP
|
$56.00
|
|
| Hospital Charge Code |
3002566
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$224.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: The Alliance Commercial |
$224.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Ace wrap applied, 3 in x2 - Treatments Done
|
Facility
IP
|
$167.00
|
|
| Hospital Charge Code |
3025941
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.83 |
| Max. Negotiated Rate |
$153.64 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$100.20
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Ace wrap applied, 3 in x2 - Treatments Done
|
Facility
OP
|
$167.00
|
|
| Hospital Charge Code |
3025941
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$668.00 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Aetna Managed Medicare |
$46.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$108.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$80.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.45
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$125.25
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$108.55
|
| Rate for Payer: Quartz Medicare Advantage |
$100.20
|
| Rate for Payer: The Alliance Commercial |
$668.00
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Ace wrap applied, 3 in x3 - Treatments Done
|
Facility
OP
|
$252.00
|
|
| Hospital Charge Code |
3025940
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$1,008.00 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$216.72
|
| Rate for Payer: Aetna Managed Medicare |
$70.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$163.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.56
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$231.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.02
|
| Rate for Payer: Health EOS Commercial |
$224.28
|
| Rate for Payer: HFN Commercial |
$231.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.00
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: NAPHCARE Commercial |
$151.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.84
|
| Rate for Payer: Quartz Beloit One Network |
$123.48
|
| Rate for Payer: Quartz Commercial |
$163.80
|
| Rate for Payer: Quartz Medicare Advantage |
$151.20
|
| Rate for Payer: The Alliance Commercial |
$1,008.00
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
Ace wrap applied, 3 in x3 - Treatments Done
|
Facility
IP
|
$252.00
|
|
| Hospital Charge Code |
3025940
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$123.48 |
| Max. Negotiated Rate |
$231.84 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.56
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$231.84
|
| Rate for Payer: Health EOS Commercial |
$224.28
|
| Rate for Payer: HFN Commercial |
$231.84
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: NAPHCARE Commercial |
$151.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.84
|
| Rate for Payer: Quartz Beloit One Network |
$123.48
|
| Rate for Payer: Quartz Commercial |
$151.20
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
Ace wrap applied, 4 in - Treatments Done
|
Facility
OP
|
$84.00
|
|
| Hospital Charge Code |
3002565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Ace wrap applied, 4 in - Treatments Done
|
Facility
IP
|
$84.00
|
|
| Hospital Charge Code |
3002565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Ace wrap applied, 6 in - Treatments Done
|
Facility
IP
|
$114.00
|
|
| Hospital Charge Code |
3002564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Ace wrap applied, 6 in - Treatments Done
|
Facility
OP
|
$114.00
|
|
| Hospital Charge Code |
3002564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Aetna Managed Medicare |
$31.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.79
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
ACHILLES TENDON REPAIR
|
Facility
OP
|
$4,492.00
|
|
| Hospital Charge Code |
2960411
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,257.76 |
| Max. Negotiated Rate |
$17,968.00 |
| Rate for Payer: Aetna Commercial |
$4,042.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,863.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,257.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,919.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,246.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,156.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,380.76
|
| Rate for Payer: Cash Price |
$1,347.60
|
| Rate for Payer: Cigna Commercial |
$4,132.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,513.72
|
| Rate for Payer: Health EOS Commercial |
$3,997.88
|
| Rate for Payer: HFN Commercial |
$4,132.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,369.00
|
| Rate for Payer: Multiplan Commercial |
$3,593.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,695.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,132.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,201.08
|
| Rate for Payer: Quartz Commercial |
$2,919.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,695.20
|
| Rate for Payer: The Alliance Commercial |
$17,968.00
|
| Rate for Payer: WEA Trust Commercial |
$2,470.60
|
| Rate for Payer: WPS Commercial |
$3,327.22
|
|
|
ACHILLES TENDON REPAIR
|
Facility
IP
|
$4,492.00
|
|
| Hospital Charge Code |
2960411
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,201.08 |
| Max. Negotiated Rate |
$4,132.64 |
| Rate for Payer: Aetna Commercial |
$4,042.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,380.76
|
| Rate for Payer: Cash Price |
$1,347.60
|
| Rate for Payer: Cigna Commercial |
$4,132.64
|
| Rate for Payer: Health EOS Commercial |
$3,997.88
|
| Rate for Payer: HFN Commercial |
$4,132.64
|
| Rate for Payer: Multiplan Commercial |
$3,593.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,695.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,132.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,201.08
|
| Rate for Payer: Quartz Commercial |
$2,695.20
|
| Rate for Payer: WEA Trust Commercial |
$2,470.60
|
| Rate for Payer: WPS Commercial |
$3,327.22
|
|
|
ACHr Bind Ab / 206
|
Professional
|
$160.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
977769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.00
|
| Rate for Payer: Health EOS Commercial |
$145.60
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$152.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.40
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
ACHr Bind Ab / 206
|
Facility
OP
|
$160.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
977769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.72
|
| Rate for Payer: Dean Health Medicaid |
$14.72
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.72
|
| Rate for Payer: Managed Health Services Medicaid |
$15.31
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.72
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$96.00
|
| Rate for Payer: The Alliance Commercial |
$640.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.72
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WMAP Medicaid |
$14.72
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
ACHr Bind Ab / 206
|
Facility
IP
|
$160.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
977769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
ACHr Blk Ab / 34459
|
Professional
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
977770
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.00
|
| Rate for Payer: Health EOS Commercial |
$145.60
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$152.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.40
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
ACHr Blk Ab / 34459
|
Facility
OP
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
977770
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.72
|
| Rate for Payer: Dean Health Medicaid |
$14.72
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.72
|
| Rate for Payer: Managed Health Services Medicaid |
$15.31
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.72
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$96.00
|
| Rate for Payer: The Alliance Commercial |
$640.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.72
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WMAP Medicaid |
$14.72
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
ACHr Blk Ab / 34459
|
Facility
IP
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
977770
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
ACHr Ganglionic Neuronal Antibody
|
Professional
|
$140.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
2942964
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Aetna Managed Medicare |
$18.40
|
| Rate for Payer: Anthem Medicare Advantage |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.40
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.40
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.40
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.60
|
| Rate for Payer: Quartz Commercial |
$79.80
|
| Rate for Payer: Quartz Medicare Advantage |
$18.40
|
| Rate for Payer: The Alliance Commercial |
$72.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.40
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$80.96
|
|
