|
CLOSURE LAP WOUND 1/PK
|
Facility
|
IP
|
$81.00
|
|
| Hospital Charge Code |
2964068
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
CLOSURE LAP WOUND 1/PK
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
2964068
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$22.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$48.60
|
| Rate for Payer: The Alliance Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
CLOSURE OF EYELID BY SUTURE 67875
|
Professional
|
Both
|
$445.00
|
|
|
Service Code
|
CPT 67875
|
| Hospital Charge Code |
3015246
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.43 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Aetna Commercial |
$422.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$422.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.00
|
| Rate for Payer: Health EOS Commercial |
$404.95
|
| Rate for Payer: HFN Commercial |
$422.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$320.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$320.70
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: Preferred Network Access Commercial |
$422.75
|
| Rate for Payer: Quartz Beloit One Network |
$195.80
|
| Rate for Payer: Quartz Commercial |
$253.65
|
| Rate for Payer: The Alliance Commercial |
$222.50
|
| Rate for Payer: United Healthcare Medicaid |
$60.43
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
CLOSURE OF SPLIT WOUND 12020
|
Professional
|
Both
|
$739.00
|
|
|
Service Code
|
CPT 12020
|
| Hospital Charge Code |
3013590
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.75 |
| Max. Negotiated Rate |
$702.05 |
| Rate for Payer: Aetna Commercial |
$702.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$635.54
|
| Rate for Payer: Cash Price |
$221.70
|
| Rate for Payer: Cash Price |
$221.70
|
| Rate for Payer: Cigna Commercial |
$702.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$443.40
|
| Rate for Payer: Health EOS Commercial |
$672.49
|
| Rate for Payer: HFN Commercial |
$702.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$626.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$626.50
|
| Rate for Payer: Multiplan Commercial |
$591.20
|
| Rate for Payer: Preferred Network Access Commercial |
$702.05
|
| Rate for Payer: Quartz Beloit One Network |
$325.16
|
| Rate for Payer: Quartz Commercial |
$421.23
|
| Rate for Payer: The Alliance Commercial |
$369.50
|
| Rate for Payer: United Healthcare Medicaid |
$31.75
|
| Rate for Payer: WEA Trust Commercial |
$406.45
|
| Rate for Payer: WPS Commercial |
$547.38
|
|
|
CLOSURE OF SPLIT WOUND 12021
|
Professional
|
Both
|
$562.00
|
|
|
Service Code
|
CPT 12021
|
| Hospital Charge Code |
3013591
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$39.85 |
| Max. Negotiated Rate |
$533.90 |
| Rate for Payer: Aetna Commercial |
$533.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$483.32
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$533.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$337.20
|
| Rate for Payer: Health EOS Commercial |
$511.42
|
| Rate for Payer: HFN Commercial |
$533.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$465.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$465.36
|
| Rate for Payer: Multiplan Commercial |
$449.60
|
| Rate for Payer: Preferred Network Access Commercial |
$533.90
|
| Rate for Payer: Quartz Beloit One Network |
$247.28
|
| Rate for Payer: Quartz Commercial |
$320.34
|
| Rate for Payer: The Alliance Commercial |
$281.00
|
| Rate for Payer: United Healthcare Medicaid |
$39.85
|
| Rate for Payer: WEA Trust Commercial |
$309.10
|
| Rate for Payer: WPS Commercial |
$416.27
|
|
|
CLOSURE SYSTEM 10/12MM CARTER-THOMASON CTXL
|
Facility
|
OP
|
$2,562.00
|
|
| Hospital Charge Code |
2964984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$717.36 |
| Max. Negotiated Rate |
$10,248.00 |
| Rate for Payer: Aetna Commercial |
$2,305.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,203.32
|
| Rate for Payer: Aetna Managed Medicare |
$717.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,665.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,281.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,229.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,357.86
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cigna Commercial |
$2,357.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,433.70
|
| Rate for Payer: Health EOS Commercial |
$2,280.18
|
| Rate for Payer: HFN Commercial |
$2,357.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,921.50
|
| Rate for Payer: Multiplan Commercial |
$2,049.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,537.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,357.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,255.38
|
| Rate for Payer: Quartz Commercial |
$1,665.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,537.20
|
| Rate for Payer: The Alliance Commercial |
$10,248.00
|
| Rate for Payer: WEA Trust Commercial |
$1,409.10
|
| Rate for Payer: WPS Commercial |
$1,897.67
|
|
|
CLOSURE SYSTEM 10/12MM CARTER-THOMASON CTXL
|
Facility
|
IP
|
$2,562.00
|
|
| Hospital Charge Code |
2964984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,255.38 |
| Max. Negotiated Rate |
$2,357.04 |
| Rate for Payer: Aetna Commercial |
$2,305.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,203.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,357.86
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cigna Commercial |
$2,357.04
|
| Rate for Payer: Health EOS Commercial |
$2,280.18
|
| Rate for Payer: HFN Commercial |
$2,357.04
|
| Rate for Payer: Multiplan Commercial |
$2,049.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,537.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,357.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,255.38
|
| Rate for Payer: Quartz Commercial |
$1,537.20
|
| Rate for Payer: WEA Trust Commercial |
$1,409.10
|
| Rate for Payer: WPS Commercial |
$1,897.67
|
|
|
CLOSURE SYSTEM 5MM CARTER-THOMASON CTI-512N
|
Facility
|
IP
|
$1,878.00
|
|
| Hospital Charge Code |
2964983
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$920.22 |
| Max. Negotiated Rate |
$1,727.76 |
| Rate for Payer: Aetna Commercial |
$1,690.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,615.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$995.34
|
| Rate for Payer: Cash Price |
$563.40
|
| Rate for Payer: Cigna Commercial |
$1,727.76
|
| Rate for Payer: Health EOS Commercial |
$1,671.42
|
| Rate for Payer: HFN Commercial |
$1,727.76
|
| Rate for Payer: Multiplan Commercial |
$1,502.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,126.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.76
|
| Rate for Payer: Quartz Beloit One Network |
$920.22
|
| Rate for Payer: Quartz Commercial |
$1,126.80
|
| Rate for Payer: WEA Trust Commercial |
$1,032.90
|
| Rate for Payer: WPS Commercial |
$1,391.03
|
|
|
CLOSURE SYSTEM 5MM CARTER-THOMASON CTI-512N
|
Facility
|
OP
|
$1,878.00
|
|
| Hospital Charge Code |
2964983
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$525.84 |
| Max. Negotiated Rate |
$7,512.00 |
| Rate for Payer: Aetna Commercial |
$1,690.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,615.08
|
| Rate for Payer: Aetna Managed Medicare |
$525.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,220.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$939.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$901.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$995.34
|
| Rate for Payer: Cash Price |
$563.40
|
| Rate for Payer: Cigna Commercial |
$1,727.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,050.93
|
| Rate for Payer: Health EOS Commercial |
$1,671.42
|
| Rate for Payer: HFN Commercial |
$1,727.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,408.50
|
| Rate for Payer: Multiplan Commercial |
$1,502.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,126.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,727.76
|
| Rate for Payer: Quartz Beloit One Network |
$920.22
|
| Rate for Payer: Quartz Commercial |
$1,220.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,126.80
|
| Rate for Payer: The Alliance Commercial |
$7,512.00
|
| Rate for Payer: WEA Trust Commercial |
$1,032.90
|
| Rate for Payer: WPS Commercial |
$1,391.03
|
|
|
CLOSURE SYSTEM STERNALOCK 360 MULTI-IMPLANT 74-0004
|
Facility
|
OP
|
$18,808.00
|
|
| Hospital Charge Code |
5415794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,266.24 |
| Max. Negotiated Rate |
$75,232.00 |
| Rate for Payer: Aetna Commercial |
$16,927.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,174.88
|
| Rate for Payer: Aetna Managed Medicare |
$5,266.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,225.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,404.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,027.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,968.24
|
| Rate for Payer: Cash Price |
$5,642.40
|
| Rate for Payer: Cigna Commercial |
$17,303.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,524.96
|
| Rate for Payer: Health EOS Commercial |
$16,739.12
|
| Rate for Payer: HFN Commercial |
$17,303.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,106.00
|
| Rate for Payer: Multiplan Commercial |
$15,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,303.36
|
| Rate for Payer: Quartz Beloit One Network |
$9,215.92
|
| Rate for Payer: Quartz Commercial |
$12,225.20
|
| Rate for Payer: Quartz Medicare Advantage |
$11,284.80
|
| Rate for Payer: The Alliance Commercial |
$75,232.00
|
| Rate for Payer: WEA Trust Commercial |
$10,344.40
|
| Rate for Payer: WPS Commercial |
$13,931.09
|
|
|
CLOSURE SYSTEM STERNALOCK 360 MULTI-IMPLANT 74-0004
|
Facility
|
IP
|
$18,808.00
|
|
| Hospital Charge Code |
5415794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,215.92 |
| Max. Negotiated Rate |
$17,303.36 |
| Rate for Payer: Aetna Commercial |
$16,927.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,174.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,968.24
|
| Rate for Payer: Cash Price |
$5,642.40
|
| Rate for Payer: Cigna Commercial |
$17,303.36
|
| Rate for Payer: Health EOS Commercial |
$16,739.12
|
| Rate for Payer: HFN Commercial |
$17,303.36
|
| Rate for Payer: Multiplan Commercial |
$15,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,303.36
|
| Rate for Payer: Quartz Beloit One Network |
$9,215.92
|
| Rate for Payer: Quartz Commercial |
$11,284.80
|
| Rate for Payer: WEA Trust Commercial |
$10,344.40
|
| Rate for Payer: WPS Commercial |
$13,931.09
|
|
|
CLOTH CHG PATIENT SKIN PREP 9707
|
Facility
|
IP
|
$86.00
|
|
| Hospital Charge Code |
5298708
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.14 |
| Max. Negotiated Rate |
$79.12 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$51.60
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
CLOTH CHG PATIENT SKIN PREP 9707
|
Facility
|
OP
|
$86.00
|
|
| Hospital Charge Code |
5298708
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$344.00 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Aetna Managed Medicare |
$24.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.13
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.50
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$55.90
|
| Rate for Payer: Quartz Medicare Advantage |
$51.60
|
| Rate for Payer: The Alliance Commercial |
$344.00
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
CLOUD WALKR ORTH LG M 10-11 W 12-13 L3040
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607692
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$166.79 |
| Rate for Payer: Aetna Commercial |
$26.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.80
|
| Rate for Payer: Health EOS Commercial |
$25.48
|
| Rate for Payer: HFN Commercial |
$26.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$166.79
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.60
|
| Rate for Payer: Quartz Beloit One Network |
$12.32
|
| Rate for Payer: Quartz Commercial |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$14.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH LG M 10-11 W 12-13 L3040
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607692
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH LG M 10-11 W 12-13 L3040
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607692
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH MED M 8-9 W 10-11 L3040
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$166.79 |
| Rate for Payer: Aetna Commercial |
$26.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.80
|
| Rate for Payer: Health EOS Commercial |
$25.48
|
| Rate for Payer: HFN Commercial |
$26.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$166.79
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.60
|
| Rate for Payer: Quartz Beloit One Network |
$12.32
|
| Rate for Payer: Quartz Commercial |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$14.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH MED M 8-9 W 10-11 L3040
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH MED M 8-9 W 10-11 L3040
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH SM M 6-7 W 8-9 L3040
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607694
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$166.79 |
| Rate for Payer: Aetna Commercial |
$26.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.80
|
| Rate for Payer: Health EOS Commercial |
$25.48
|
| Rate for Payer: HFN Commercial |
$26.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$166.79
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.60
|
| Rate for Payer: Quartz Beloit One Network |
$12.32
|
| Rate for Payer: Quartz Commercial |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$14.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH SM M 6-7 W 8-9 L3040
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607694
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH SM M 6-7 W 8-9 L3040
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607694
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH XLG M 12-13 W 14-15 L3040
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607689
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH XLG M 12-13 W 14-15 L3040
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607689
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
CLOUD WALKR ORTH XLG M 12-13 W 14-15 L3040
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607689
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$166.79 |
| Rate for Payer: Aetna Commercial |
$26.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.80
|
| Rate for Payer: Health EOS Commercial |
$25.48
|
| Rate for Payer: HFN Commercial |
$26.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$166.79
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.60
|
| Rate for Payer: Quartz Beloit One Network |
$12.32
|
| Rate for Payer: Quartz Commercial |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$14.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
