|
CLOUD WALKR ORTH XS M 4-5 W 5-7 L3040
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607690
|
|
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 XS M 4-5 W 5-7 L3040
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607690
|
|
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 XS M 4-5 W 5-7 L3040
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607690
|
|
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 XXLG M 14-15 L3040
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607691
|
|
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 XXLG M 14-15 L3040
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607691
|
|
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 XXLG M 14-15 L3040
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
5607691
|
|
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
|
|
|
Clozapine Level
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
977905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.15 |
| Max. Negotiated Rate |
$264.04 |
| Rate for Payer: Aetna Commercial |
$258.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Aetna Managed Medicare |
$20.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.45
|
| Rate for Payer: Anthem Medicaid |
$20.18
|
| Rate for Payer: Anthem Medicare Advantage |
$20.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.15
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$264.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.61
|
| Rate for Payer: Dean Health Medicaid |
$20.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.15
|
| Rate for Payer: Health EOS Commercial |
$255.43
|
| Rate for Payer: HFN Commercial |
$264.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.15
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$20.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.15
|
| Rate for Payer: Managed Health Services Medicaid |
$20.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.15
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: NAPHCARE Commercial |
$30.22
|
| Rate for Payer: Preferred Network Access Commercial |
$264.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20.18
|
| Rate for Payer: Quartz Beloit One Network |
$140.63
|
| Rate for Payer: Quartz Commercial |
$186.55
|
| Rate for Payer: Quartz Medicare Advantage |
$20.15
|
| Rate for Payer: The Alliance Commercial |
$80.60
|
| Rate for Payer: United Healthcare Medicaid |
$20.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.15
|
| Rate for Payer: United Healthcare PPO |
$215.25
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: Wellcare Medicare |
$20.15
|
| Rate for Payer: WMAP Medicaid |
$20.18
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
Clozapine Level
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
977905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$140.63 |
| Max. Negotiated Rate |
$264.04 |
| Rate for Payer: Aetna Commercial |
$258.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.11
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$264.04
|
| Rate for Payer: Health EOS Commercial |
$255.43
|
| Rate for Payer: HFN Commercial |
$264.04
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: NAPHCARE Commercial |
$172.20
|
| Rate for Payer: Preferred Network Access Commercial |
$264.04
|
| Rate for Payer: Quartz Beloit One Network |
$140.63
|
| Rate for Payer: Quartz Commercial |
$172.20
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
Clozapine Level
|
Professional
|
Both
|
$287.00
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
977905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.13 |
| Max. Negotiated Rate |
$272.65 |
| Rate for Payer: Aetna Commercial |
$272.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$272.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$143.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.20
|
| Rate for Payer: Health EOS Commercial |
$261.17
|
| Rate for Payer: HFN Commercial |
$272.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$71.13
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.65
|
| Rate for Payer: Quartz Beloit One Network |
$126.28
|
| Rate for Payer: Quartz Commercial |
$163.59
|
| Rate for Payer: The Alliance Commercial |
$143.50
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
CLTX MED ANKLE FX W/MNPJ 27762
|
Professional
|
Both
|
$1,216.00
|
|
|
Service Code
|
CPT 27762
|
| Hospital Charge Code |
3014145
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$415.38 |
| Max. Negotiated Rate |
$1,445.78 |
| Rate for Payer: Aetna Commercial |
$1,155.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,045.76
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Cigna Commercial |
$1,155.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$415.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$729.60
|
| Rate for Payer: Health EOS Commercial |
$1,106.56
|
| Rate for Payer: HFN Commercial |
$1,155.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,445.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,445.78
|
| Rate for Payer: Multiplan Commercial |
$972.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,155.20
|
| Rate for Payer: Quartz Beloit One Network |
$535.04
|
| Rate for Payer: Quartz Commercial |
$693.12
|
| Rate for Payer: The Alliance Commercial |
$608.00
|
| Rate for Payer: United Healthcare Medicaid |
$415.38
|
| Rate for Payer: WEA Trust Commercial |
$668.80
|
| Rate for Payer: WPS Commercial |
$900.69
|
|
|
CLTX POST ANKLE FX 27767
|
Professional
|
Both
|
$781.00
|
|
|
Service Code
|
CPT 27767
|
| Hospital Charge Code |
3014147
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$177.53 |
| Max. Negotiated Rate |
$976.19 |
| Rate for Payer: Aetna Commercial |
$741.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$671.66
|
| Rate for Payer: Cash Price |
$234.30
|
| Rate for Payer: Cash Price |
$234.30
|
| Rate for Payer: Cigna Commercial |
$741.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$177.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$468.60
|
| Rate for Payer: Health EOS Commercial |
$710.71
|
| Rate for Payer: HFN Commercial |
$741.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$976.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$976.19
|
| Rate for Payer: Multiplan Commercial |
$624.80
|
| Rate for Payer: Preferred Network Access Commercial |
$741.95
|
| Rate for Payer: Quartz Beloit One Network |
$343.64
|
| Rate for Payer: Quartz Commercial |
$445.17
|
| Rate for Payer: The Alliance Commercial |
$390.50
|
| Rate for Payer: United Healthcare Medicaid |
$177.53
|
| Rate for Payer: WEA Trust Commercial |
$429.55
|
| Rate for Payer: WPS Commercial |
$578.49
|
|
|
CLUB FOOT DEFORMITY REPAIR
|
Facility
|
OP
|
$4,560.00
|
|
| Hospital Charge Code |
2959935
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,276.80 |
| Max. Negotiated Rate |
$18,240.00 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,276.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,964.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,280.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,188.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,551.78
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,420.00
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,736.00
|
| Rate for Payer: The Alliance Commercial |
$18,240.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
CLUB FOOT DEFORMITY REPAIR
|
Facility
|
IP
|
$4,560.00
|
|
| Hospital Charge Code |
2959935
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,234.40 |
| Max. Negotiated Rate |
$4,195.20 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
Cmptr ophth dx img ant segmt 92132
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
CPT 92132
|
| Hospital Charge Code |
3015326
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$107.31 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.80
|
| Rate for Payer: Health EOS Commercial |
$89.18
|
| Rate for Payer: HFN Commercial |
$93.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.31
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: Preferred Network Access Commercial |
$93.10
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$55.86
|
| Rate for Payer: The Alliance Commercial |
$49.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.08
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
Cmptr ophth dx img ant segmt 9213226
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
CPT 92132 26
|
| Hospital Charge Code |
3015327
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$93.10 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.80
|
| Rate for Payer: Health EOS Commercial |
$89.18
|
| Rate for Payer: HFN Commercial |
$93.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.88
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: Preferred Network Access Commercial |
$93.10
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$55.86
|
| Rate for Payer: The Alliance Commercial |
$49.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
CMS SCORING ASSISTANT
|
Facility
|
IP
|
$6,397.00
|
|
| Hospital Charge Code |
2973707
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3,134.53 |
| Max. Negotiated Rate |
$5,885.24 |
| Rate for Payer: Aetna Commercial |
$5,757.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,501.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,390.41
|
| Rate for Payer: Cash Price |
$1,919.10
|
| Rate for Payer: Cigna Commercial |
$5,885.24
|
| Rate for Payer: Health EOS Commercial |
$5,693.33
|
| Rate for Payer: HFN Commercial |
$5,885.24
|
| Rate for Payer: Multiplan Commercial |
$5,117.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,838.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,885.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,134.53
|
| Rate for Payer: Quartz Commercial |
$3,838.20
|
| Rate for Payer: WEA Trust Commercial |
$3,518.35
|
| Rate for Payer: WPS Commercial |
$4,738.26
|
|
|
CMS SCORING ASSISTANT
|
Facility
|
OP
|
$6,397.00
|
|
| Hospital Charge Code |
2973707
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,791.16 |
| Max. Negotiated Rate |
$25,588.00 |
| Rate for Payer: Aetna Commercial |
$5,757.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,501.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,791.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,158.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,198.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,070.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,390.41
|
| Rate for Payer: Cash Price |
$1,919.10
|
| Rate for Payer: Cigna Commercial |
$5,885.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,579.76
|
| Rate for Payer: Health EOS Commercial |
$5,693.33
|
| Rate for Payer: HFN Commercial |
$5,885.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,797.75
|
| Rate for Payer: Multiplan Commercial |
$5,117.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,838.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,885.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,134.53
|
| Rate for Payer: Quartz Commercial |
$4,158.05
|
| Rate for Payer: Quartz Medicare Advantage |
$3,838.20
|
| Rate for Payer: The Alliance Commercial |
$25,588.00
|
| Rate for Payer: WEA Trust Commercial |
$3,518.35
|
| Rate for Payer: WPS Commercial |
$4,738.26
|
|
|
CMV Ab IgM, CSF
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
4597184
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$63.48 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$41.40
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$41.40
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
CMV Ab IgM, CSF
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
4597184
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$67.40 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Aetna Managed Medicare |
$16.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.49
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.97
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$16.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.85
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.61
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.85
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.85
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.85
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.85
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$25.28
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$44.85
|
| Rate for Payer: Quartz Medicare Advantage |
$16.85
|
| Rate for Payer: The Alliance Commercial |
$67.40
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.85
|
| Rate for Payer: United Healthcare PPO |
$51.75
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: Wellcare Medicare |
$16.85
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
CMV Ab IgM, CSF
|
Professional
|
Both
|
$69.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
4597184
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.36 |
| Max. Negotiated Rate |
$65.55 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.40
|
| Rate for Payer: Health EOS Commercial |
$62.79
|
| Rate for Payer: HFN Commercial |
$65.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.48
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$65.55
|
| Rate for Payer: Quartz Beloit One Network |
$30.36
|
| Rate for Payer: Quartz Commercial |
$39.33
|
| Rate for Payer: The Alliance Commercial |
$34.50
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
CMV Antibody IgM
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
2943018
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.98 |
| Max. Negotiated Rate |
$93.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$61.20
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
CMV Antibody IgM
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
2943018
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.88 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Aetna Commercial |
$96.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$96.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.20
|
| Rate for Payer: Health EOS Commercial |
$92.82
|
| Rate for Payer: HFN Commercial |
$96.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.48
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: Preferred Network Access Commercial |
$96.90
|
| Rate for Payer: Quartz Beloit One Network |
$44.88
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: The Alliance Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
CMV Antibody IgM
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
2943018
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$93.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$16.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.49
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.97
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$16.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.85
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.85
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.85
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.85
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.85
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.28
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$16.85
|
| Rate for Payer: The Alliance Commercial |
$67.40
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.85
|
| Rate for Payer: United Healthcare PPO |
$76.50
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: Wellcare Medicare |
$16.85
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
CMV Genotype
|
Professional
|
Both
|
$704.00
|
|
|
Service Code
|
CPT 87910
|
| Hospital Charge Code |
4732608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$309.76 |
| Max. Negotiated Rate |
$908.80 |
| Rate for Payer: Aetna Commercial |
$668.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$605.44
|
| Rate for Payer: Cash Price |
$211.20
|
| Rate for Payer: Cash Price |
$211.20
|
| Rate for Payer: Cigna Commercial |
$668.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$352.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$422.40
|
| Rate for Payer: Health EOS Commercial |
$640.64
|
| Rate for Payer: HFN Commercial |
$668.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$908.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$908.80
|
| Rate for Payer: Multiplan Commercial |
$563.20
|
| Rate for Payer: Preferred Network Access Commercial |
$668.80
|
| Rate for Payer: Quartz Beloit One Network |
$309.76
|
| Rate for Payer: Quartz Commercial |
$401.28
|
| Rate for Payer: The Alliance Commercial |
$352.00
|
| Rate for Payer: WEA Trust Commercial |
$387.20
|
| Rate for Payer: WPS Commercial |
$521.45
|
|
|
CMV Genotype
|
Facility
|
OP
|
$704.00
|
|
|
Service Code
|
CPT 87910
|
| Hospital Charge Code |
4732608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$257.45 |
| Max. Negotiated Rate |
$1,029.80 |
| Rate for Payer: Aetna Commercial |
$633.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$605.44
|
| Rate for Payer: Aetna Managed Medicare |
$257.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$965.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$450.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$427.37
|
| Rate for Payer: Anthem Medicaid |
$266.02
|
| Rate for Payer: Anthem Medicare Advantage |
$257.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$257.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$257.45
|
| Rate for Payer: Cash Price |
$211.20
|
| Rate for Payer: Cash Price |
$211.20
|
| Rate for Payer: Cigna Commercial |
$647.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$257.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$266.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$393.96
|
| Rate for Payer: Dean Health Medicaid |
$266.02
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$257.45
|
| Rate for Payer: Health EOS Commercial |
$626.56
|
| Rate for Payer: HFN Commercial |
$647.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$957.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$257.45
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$266.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$257.45
|
| Rate for Payer: Managed Health Services Medicaid |
$276.66
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$257.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$257.45
|
| Rate for Payer: Multiplan Commercial |
$563.20
|
| Rate for Payer: NAPHCARE Commercial |
$386.18
|
| Rate for Payer: Preferred Network Access Commercial |
$647.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$266.02
|
| Rate for Payer: Quartz Beloit One Network |
$344.96
|
| Rate for Payer: Quartz Commercial |
$457.60
|
| Rate for Payer: Quartz Medicare Advantage |
$257.45
|
| Rate for Payer: The Alliance Commercial |
$1,029.80
|
| Rate for Payer: United Healthcare Medicaid |
$266.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$257.45
|
| Rate for Payer: United Healthcare PPO |
$528.00
|
| Rate for Payer: WEA Trust Commercial |
$387.20
|
| Rate for Payer: Wellcare Medicare |
$257.45
|
| Rate for Payer: WMAP Medicaid |
$266.02
|
| Rate for Payer: WPS Commercial |
$521.45
|
|
