|
Adult Ezio
|
Facility
IP
|
$231.00
|
|
| Hospital Charge Code |
3040371
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.19 |
| Max. Negotiated Rate |
$212.52 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.43
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$212.52
|
| Rate for Payer: Health EOS Commercial |
$205.59
|
| Rate for Payer: HFN Commercial |
$212.52
|
| Rate for Payer: Multiplan Commercial |
$184.80
|
| Rate for Payer: NAPHCARE Commercial |
$138.60
|
| Rate for Payer: Preferred Network Access Commercial |
$212.52
|
| Rate for Payer: Quartz Beloit One Network |
$113.19
|
| Rate for Payer: Quartz Commercial |
$138.60
|
| Rate for Payer: WEA Trust Commercial |
$127.05
|
| Rate for Payer: WPS Commercial |
$171.10
|
|
|
Adult Ezio
|
Facility
OP
|
$231.00
|
|
| Hospital Charge Code |
3040371
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.68 |
| Max. Negotiated Rate |
$924.00 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.66
|
| Rate for Payer: Aetna Managed Medicare |
$64.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$110.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.43
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$212.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.27
|
| Rate for Payer: Health EOS Commercial |
$205.59
|
| Rate for Payer: HFN Commercial |
$212.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$173.25
|
| Rate for Payer: Multiplan Commercial |
$184.80
|
| Rate for Payer: NAPHCARE Commercial |
$138.60
|
| Rate for Payer: Preferred Network Access Commercial |
$212.52
|
| Rate for Payer: Quartz Beloit One Network |
$113.19
|
| Rate for Payer: Quartz Commercial |
$150.15
|
| Rate for Payer: Quartz Medicare Advantage |
$138.60
|
| Rate for Payer: The Alliance Commercial |
$924.00
|
| Rate for Payer: WEA Trust Commercial |
$127.05
|
| Rate for Payer: WPS Commercial |
$171.10
|
|
|
Advanced Care Planning 99497
|
Professional
|
$209.00
|
|
|
Service Code
|
CPT 99497
|
| Hospital Charge Code |
4598878
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.27 |
| Max. Negotiated Rate |
$263.83 |
| Rate for Payer: Aetna Commercial |
$198.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Aetna Managed Medicare |
$72.18
|
| Rate for Payer: Anthem Medicare Advantage |
$72.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$72.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$72.18
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$198.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.18
|
| Rate for Payer: Health EOS Commercial |
$190.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$263.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$263.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$72.18
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: Preferred Network Access Commercial |
$198.55
|
| Rate for Payer: Quartz Beloit One Network |
$91.96
|
| Rate for Payer: Quartz Commercial |
$119.13
|
| Rate for Payer: Quartz Medicare Advantage |
$72.18
|
| Rate for Payer: The Alliance Commercial |
$173.23
|
| Rate for Payer: United Healthcare Medicaid |
$63.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.18
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$198.50
|
|
|
Advanced Care Planning Ea Add 30 min 99498
|
Professional
|
$140.00
|
|
|
Service Code
|
CPT 99498
|
| Hospital Charge Code |
4598877
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$248.83 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| 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 |
$84.00
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$248.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$248.83
|
| 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: The Alliance Commercial |
$70.00
|
| Rate for Payer: United Healthcare Medicaid |
$63.27
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
AEP HEARING STATUS DETER BRDBAND STIMULI I&R -92651
|
Facility
OP
|
$424.00
|
|
|
Service Code
|
CPT 92651
|
| Hospital Charge Code |
5781703
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$203.52 |
| Max. Negotiated Rate |
$1,154.09 |
| Rate for Payer: Aetna Commercial |
$381.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$364.64
|
| Rate for Payer: Aetna Managed Medicare |
$310.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$275.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$212.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$203.52
|
| Rate for Payer: Anthem Medicare Advantage |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$224.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$310.24
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cigna Commercial |
$390.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$310.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$237.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$310.24
|
| Rate for Payer: Health EOS Commercial |
$377.36
|
| Rate for Payer: HFN Commercial |
$390.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,154.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$310.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$310.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$310.24
|
| Rate for Payer: Multiplan Commercial |
$339.20
|
| Rate for Payer: NAPHCARE Commercial |
$465.36
|
| Rate for Payer: Preferred Network Access Commercial |
$390.08
|
| Rate for Payer: Quartz Beloit One Network |
$207.76
|
| Rate for Payer: Quartz Commercial |
$275.60
|
| Rate for Payer: Quartz Medicare Advantage |
$310.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$310.24
|
| Rate for Payer: United Healthcare PPO |
$318.00
|
| Rate for Payer: WEA Trust Commercial |
$233.20
|
| Rate for Payer: Wellcare Medicare |
$310.24
|
| Rate for Payer: WPS Commercial |
$314.06
|
|
|
AEP HEARING STATUS DETER BRDBAND STIMULI I&R -92651
|
Facility
IP
|
$424.00
|
|
|
Service Code
|
CPT 92651
|
| Hospital Charge Code |
5781703
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$207.76 |
| Max. Negotiated Rate |
$390.08 |
| Rate for Payer: Aetna Commercial |
$381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$224.72
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cigna Commercial |
$390.08
|
| Rate for Payer: Health EOS Commercial |
$377.36
|
| Rate for Payer: HFN Commercial |
$390.08
|
| Rate for Payer: Multiplan Commercial |
$339.20
|
| Rate for Payer: NAPHCARE Commercial |
$254.40
|
| Rate for Payer: Preferred Network Access Commercial |
$390.08
|
| Rate for Payer: Quartz Beloit One Network |
$207.76
|
| Rate for Payer: Quartz Commercial |
$254.40
|
| Rate for Payer: WEA Trust Commercial |
$233.20
|
| Rate for Payer: WPS Commercial |
$314.06
|
|
|
AEP SCR AUD POTENTIAL W/STIMULI AUTO ALYS -92650
|
Facility
OP
|
$106.00
|
|
|
Service Code
|
CPT 92650
|
| Hospital Charge Code |
5781702
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$29.68 |
| Max. Negotiated Rate |
$424.00 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Aetna Managed Medicare |
$29.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.32
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.50
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$68.90
|
| Rate for Payer: Quartz Medicare Advantage |
$63.60
|
| Rate for Payer: The Alliance Commercial |
$424.00
|
| Rate for Payer: United Healthcare PPO |
$79.50
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
AEP SCR AUD POTENTIAL W/STIMULI AUTO ALYS -92650
|
Facility
IP
|
$106.00
|
|
|
Service Code
|
CPT 92650
|
| Hospital Charge Code |
5781702
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$63.60
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
Aerobe ID MALDI
|
Facility
OP
|
$83.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
6195681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$332.00 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$8.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.41
|
| Rate for Payer: Anthem Medicaid |
$8.35
|
| Rate for Payer: Anthem Medicare Advantage |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.08
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.35
|
| Rate for Payer: Dean Health Medicaid |
$8.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.08
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.08
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.08
|
| Rate for Payer: Managed Health Services Medicaid |
$8.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.08
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.08
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$12.12
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.35
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$53.95
|
| Rate for Payer: Quartz Medicare Advantage |
$8.08
|
| Rate for Payer: The Alliance Commercial |
$332.00
|
| Rate for Payer: United Healthcare Medicaid |
$8.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.08
|
| Rate for Payer: United Healthcare PPO |
$62.25
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: Wellcare Medicare |
$8.08
|
| Rate for Payer: WMAP Medicaid |
$8.35
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
Aerobe ID MALDI
|
Facility
IP
|
$83.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
6195681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$76.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
Aerobe ID MALDI
|
Professional
|
$83.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
6195681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$8.08
|
| Rate for Payer: Anthem Medicare Advantage |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.08
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.08
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.08
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: Quartz Medicare Advantage |
$8.08
|
| Rate for Payer: The Alliance Commercial |
$31.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.08
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Aerosol Inhalation 94640 - Admin Aerosol Inhalation Charge
|
Professional
|
$168.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
3023775
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Aetna Commercial |
$159.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.48
|
| Rate for Payer: Aetna Managed Medicare |
$8.48
|
| Rate for Payer: Anthem Medicare Advantage |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.48
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$159.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.48
|
| Rate for Payer: Health EOS Commercial |
$152.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.48
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$159.60
|
| Rate for Payer: Quartz Beloit One Network |
$73.92
|
| Rate for Payer: Quartz Commercial |
$95.76
|
| Rate for Payer: Quartz Medicare Advantage |
$8.48
|
| Rate for Payer: The Alliance Commercial |
$21.20
|
| Rate for Payer: United Healthcare Medicaid |
$11.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.48
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: WPS Commercial |
$33.92
|
|
|
Aerosol Inhalation 94640 - Admin Aerosol Inhalation Charge
|
Facility
OP
|
$168.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
3023775
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$80.64 |
| Max. Negotiated Rate |
$784.25 |
| Rate for Payer: Aetna Commercial |
$151.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.48
|
| Rate for Payer: Aetna Managed Medicare |
$210.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$109.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$80.64
|
| Rate for Payer: Anthem Medicare Advantage |
$210.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$210.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$210.82
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$154.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$210.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$210.82
|
| Rate for Payer: Health EOS Commercial |
$149.52
|
| Rate for Payer: HFN Commercial |
$154.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$210.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$210.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$210.82
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: NAPHCARE Commercial |
$316.23
|
| Rate for Payer: Preferred Network Access Commercial |
$154.56
|
| Rate for Payer: Quartz Beloit One Network |
$82.32
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: Quartz Medicare Advantage |
$210.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.82
|
| Rate for Payer: United Healthcare PPO |
$126.00
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: Wellcare Medicare |
$210.82
|
| Rate for Payer: WPS Commercial |
$124.44
|
|
|
Aerosol Inhalation 94640 - Admin Aerosol Inhalation Charge
|
Facility
IP
|
$168.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
3023775
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$82.32 |
| Max. Negotiated Rate |
$154.56 |
| Rate for Payer: Aetna Commercial |
$151.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.04
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$154.56
|
| Rate for Payer: Health EOS Commercial |
$149.52
|
| Rate for Payer: HFN Commercial |
$154.56
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: NAPHCARE Commercial |
$100.80
|
| Rate for Payer: Preferred Network Access Commercial |
$154.56
|
| Rate for Payer: Quartz Beloit One Network |
$82.32
|
| Rate for Payer: Quartz Commercial |
$100.80
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: WPS Commercial |
$124.44
|
|
|
Affinity per sq cm Q4159
|
Facility
IP
|
$1,135.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5362662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$556.15 |
| Max. Negotiated Rate |
$1,044.20 |
| Rate for Payer: Aetna Commercial |
$1,021.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$601.55
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,044.20
|
| Rate for Payer: Health EOS Commercial |
$1,010.15
|
| Rate for Payer: HFN Commercial |
$1,044.20
|
| Rate for Payer: Multiplan Commercial |
$908.00
|
| Rate for Payer: NAPHCARE Commercial |
$681.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,044.20
|
| Rate for Payer: Quartz Beloit One Network |
$556.15
|
| Rate for Payer: Quartz Commercial |
$681.00
|
| Rate for Payer: WEA Trust Commercial |
$624.25
|
| Rate for Payer: WPS Commercial |
$840.69
|
|
|
Affinity per sq cm Q4159
|
Professional
|
$1,135.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5362662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$309.58 |
| Max. Negotiated Rate |
$2,275.01 |
| Rate for Payer: Aetna Commercial |
$1,078.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.10
|
| Rate for Payer: Aetna Managed Medicare |
$420.54
|
| Rate for Payer: Anthem Medicare Advantage |
$420.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$420.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$420.54
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,078.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$567.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.58
|
| Rate for Payer: Health EOS Commercial |
$1,032.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,275.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,275.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$420.54
|
| Rate for Payer: Multiplan Commercial |
$908.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,078.25
|
| Rate for Payer: Quartz Beloit One Network |
$499.40
|
| Rate for Payer: Quartz Commercial |
$646.95
|
| Rate for Payer: Quartz Medicare Advantage |
$420.54
|
| Rate for Payer: The Alliance Commercial |
$1,156.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$420.54
|
| Rate for Payer: WEA Trust Commercial |
$624.25
|
| Rate for Payer: WPS Commercial |
$773.94
|
|
|
Affinity per sq cm Q4159
|
Facility
OP
|
$1,135.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5362662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.80 |
| Max. Negotiated Rate |
$1,044.20 |
| Rate for Payer: Aetna Commercial |
$1,021.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.10
|
| Rate for Payer: Aetna Managed Medicare |
$317.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$737.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$567.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$544.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$601.55
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,044.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$409.57
|
| Rate for Payer: Health EOS Commercial |
$1,010.15
|
| Rate for Payer: HFN Commercial |
$1,044.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$851.25
|
| Rate for Payer: Multiplan Commercial |
$908.00
|
| Rate for Payer: NAPHCARE Commercial |
$681.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,044.20
|
| Rate for Payer: Quartz Beloit One Network |
$556.15
|
| Rate for Payer: Quartz Commercial |
$737.75
|
| Rate for Payer: Quartz Medicare Advantage |
$681.00
|
| Rate for Payer: The Alliance Commercial |
$346.32
|
| Rate for Payer: WEA Trust Commercial |
$624.25
|
| Rate for Payer: WPS Commercial |
$773.94
|
|
|
Afo ankle gauntlet L1902
|
Professional
|
$134.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
3133612
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$58.96 |
| Max. Negotiated Rate |
$264.50 |
| Rate for Payer: Aetna Commercial |
$127.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.24
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$127.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.40
|
| Rate for Payer: Health EOS Commercial |
$121.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$264.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$264.50
|
| Rate for Payer: Multiplan Commercial |
$107.20
|
| Rate for Payer: Preferred Network Access Commercial |
$127.30
|
| Rate for Payer: Quartz Beloit One Network |
$58.96
|
| Rate for Payer: Quartz Commercial |
$76.38
|
| Rate for Payer: The Alliance Commercial |
$67.00
|
| Rate for Payer: WEA Trust Commercial |
$73.70
|
| Rate for Payer: WPS Commercial |
$99.25
|
|
|
Afo ankle gauntlet L1902
|
Facility
OP
|
$134.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
3133612
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$37.52 |
| Max. Negotiated Rate |
$536.00 |
| Rate for Payer: Aetna Commercial |
$120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.24
|
| Rate for Payer: Aetna Managed Medicare |
$37.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.02
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$123.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.99
|
| Rate for Payer: Health EOS Commercial |
$119.26
|
| Rate for Payer: HFN Commercial |
$123.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.50
|
| Rate for Payer: Multiplan Commercial |
$107.20
|
| Rate for Payer: NAPHCARE Commercial |
$80.40
|
| Rate for Payer: Preferred Network Access Commercial |
$123.28
|
| Rate for Payer: Quartz Beloit One Network |
$65.66
|
| Rate for Payer: Quartz Commercial |
$87.10
|
| Rate for Payer: Quartz Medicare Advantage |
$80.40
|
| Rate for Payer: The Alliance Commercial |
$536.00
|
| Rate for Payer: WEA Trust Commercial |
$73.70
|
| Rate for Payer: WPS Commercial |
$99.25
|
|
|
Afo ankle gauntlet L1902
|
Facility
IP
|
$134.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
3133612
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$65.66 |
| Max. Negotiated Rate |
$123.28 |
| Rate for Payer: Aetna Commercial |
$120.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.02
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$123.28
|
| Rate for Payer: Health EOS Commercial |
$119.26
|
| Rate for Payer: HFN Commercial |
$123.28
|
| Rate for Payer: Multiplan Commercial |
$107.20
|
| Rate for Payer: NAPHCARE Commercial |
$80.40
|
| Rate for Payer: Preferred Network Access Commercial |
$123.28
|
| Rate for Payer: Quartz Beloit One Network |
$65.66
|
| Rate for Payer: Quartz Commercial |
$80.40
|
| Rate for Payer: WEA Trust Commercial |
$73.70
|
| Rate for Payer: WPS Commercial |
$99.25
|
|
|
Afo molded to patient plasti L1940
|
Facility
IP
|
$1,244.00
|
|
|
Service Code
|
HCPCS L1940
|
| Hospital Charge Code |
4075824
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$609.56 |
| Max. Negotiated Rate |
$1,144.48 |
| Rate for Payer: Aetna Commercial |
$1,119.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$659.32
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$1,144.48
|
| Rate for Payer: Health EOS Commercial |
$1,107.16
|
| Rate for Payer: HFN Commercial |
$1,144.48
|
| Rate for Payer: Multiplan Commercial |
$995.20
|
| Rate for Payer: NAPHCARE Commercial |
$746.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,144.48
|
| Rate for Payer: Quartz Beloit One Network |
$609.56
|
| Rate for Payer: Quartz Commercial |
$746.40
|
| Rate for Payer: WEA Trust Commercial |
$684.20
|
| Rate for Payer: WPS Commercial |
$921.43
|
|
|
Afo molded to patient plasti L1940
|
Professional
|
$1,244.00
|
|
|
Service Code
|
HCPCS L1940
|
| Hospital Charge Code |
4075824
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$547.36 |
| Max. Negotiated Rate |
$1,725.61 |
| Rate for Payer: Aetna Commercial |
$1,181.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,069.84
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$1,181.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$622.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$746.40
|
| Rate for Payer: Health EOS Commercial |
$1,132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,725.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,725.61
|
| Rate for Payer: Multiplan Commercial |
$995.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,181.80
|
| Rate for Payer: Quartz Beloit One Network |
$547.36
|
| Rate for Payer: Quartz Commercial |
$709.08
|
| Rate for Payer: The Alliance Commercial |
$622.00
|
| Rate for Payer: WEA Trust Commercial |
$684.20
|
| Rate for Payer: WPS Commercial |
$921.43
|
|
|
Afo molded to patient plasti L1940
|
Facility
OP
|
$1,244.00
|
|
|
Service Code
|
HCPCS L1940
|
| Hospital Charge Code |
4075824
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$285.76 |
| Max. Negotiated Rate |
$4,976.00 |
| Rate for Payer: Aetna Commercial |
$1,119.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,069.84
|
| Rate for Payer: Aetna Managed Medicare |
$348.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$285.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$285.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$285.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$659.32
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$1,144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$696.14
|
| Rate for Payer: Health EOS Commercial |
$1,107.16
|
| Rate for Payer: HFN Commercial |
$1,144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$933.00
|
| Rate for Payer: Multiplan Commercial |
$995.20
|
| Rate for Payer: NAPHCARE Commercial |
$746.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,144.48
|
| Rate for Payer: Quartz Beloit One Network |
$609.56
|
| Rate for Payer: Quartz Commercial |
$808.60
|
| Rate for Payer: Quartz Medicare Advantage |
$746.40
|
| Rate for Payer: The Alliance Commercial |
$4,976.00
|
| Rate for Payer: WEA Trust Commercial |
$684.20
|
| Rate for Payer: WPS Commercial |
$921.43
|
|
|
Afo multiligamentus ankle su L1906
|
Facility
OP
|
$48.00
|
|
|
Service Code
|
HCPCS L1906
|
| Hospital Charge Code |
3898157
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.86
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Afo multiligamentus ankle su L1906
|
Facility
IP
|
$48.00
|
|
|
Service Code
|
HCPCS L1906
|
| Hospital Charge Code |
3898157
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
