|
Dexamethasone Suppression Test
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
1038965
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.95 |
| Max. Negotiated Rate |
$67.81 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Aetna Managed Medicare |
$16.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.67
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.14
|
| Rate for Payer: Anthem Medicare Advantage |
$16.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.95
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.95
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.95
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: NAPHCARE Commercial |
$25.43
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$47.32
|
| Rate for Payer: Quartz Medicare Advantage |
$16.95
|
| Rate for Payer: The Alliance Commercial |
$67.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.95
|
| Rate for Payer: United Healthcare PPO |
$54.60
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: Wellcare Medicare |
$16.95
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
Dexamethasone Suppression Test
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
1038965
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.95 |
| Max. Negotiated Rate |
$74.59 |
| Rate for Payer: Aetna Commercial |
$69.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Aetna Managed Medicare |
$16.95
|
| Rate for Payer: Anthem Medicare Advantage |
$16.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.95
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$69.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.95
|
| Rate for Payer: Health EOS Commercial |
$66.25
|
| Rate for Payer: HFN Commercial |
$69.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.95
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: NAPHCARE Commercial |
$25.43
|
| Rate for Payer: Preferred Network Access Commercial |
$69.16
|
| Rate for Payer: Quartz Beloit One Network |
$32.03
|
| Rate for Payer: Quartz Commercial |
$41.50
|
| Rate for Payer: Quartz Medicare Advantage |
$16.95
|
| Rate for Payer: The Alliance Commercial |
$66.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.95
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$74.59
|
|
|
DIABETES
|
Facility
|
IP
|
$16,747.47
|
|
|
Service Code
|
APR-DRG 4204
|
| Min. Negotiated Rate |
$14,876.15 |
| Max. Negotiated Rate |
$16,747.47 |
| Rate for Payer: Anthem Medicaid |
$16,036.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$16,036.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16,036.63
|
| Rate for Payer: Dean Health Medicaid |
$16,036.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14,876.15
|
| Rate for Payer: Managed Health Services Medicaid |
$16,747.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,036.63
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16,036.63
|
| Rate for Payer: United Healthcare Medicaid |
$16,036.63
|
|
|
DIABETES
|
Facility
|
IP
|
$8,943.68
|
|
|
Service Code
|
APR-DRG 4203
|
| Min. Negotiated Rate |
$7,944.33 |
| Max. Negotiated Rate |
$8,943.68 |
| Rate for Payer: Anthem Medicaid |
$8,564.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,564.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,564.06
|
| Rate for Payer: Dean Health Medicaid |
$8,564.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,944.33
|
| Rate for Payer: Managed Health Services Medicaid |
$8,943.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,564.06
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,564.06
|
| Rate for Payer: United Healthcare Medicaid |
$8,564.06
|
|
|
DIABETES
|
Facility
|
IP
|
$4,471.84
|
|
|
Service Code
|
APR-DRG 4201
|
| Min. Negotiated Rate |
$3,972.17 |
| Max. Negotiated Rate |
$4,471.84 |
| Rate for Payer: Anthem Medicaid |
$4,282.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,282.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,282.03
|
| Rate for Payer: Dean Health Medicaid |
$4,282.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,972.17
|
| Rate for Payer: Managed Health Services Medicaid |
$4,471.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,282.03
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,282.03
|
| Rate for Payer: United Healthcare Medicaid |
$4,282.03
|
|
|
DIABETES
|
Facility
|
IP
|
$5,874.77
|
|
|
Service Code
|
APR-DRG 4202
|
| Min. Negotiated Rate |
$5,218.34 |
| Max. Negotiated Rate |
$5,874.77 |
| Rate for Payer: Anthem Medicaid |
$5,625.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,625.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,625.41
|
| Rate for Payer: Dean Health Medicaid |
$5,625.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,218.34
|
| Rate for Payer: Managed Health Services Medicaid |
$5,874.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,625.41
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,625.41
|
| Rate for Payer: United Healthcare Medicaid |
$5,625.41
|
|
|
DIABETES WITH CC
|
Facility
|
IP
|
$25,201.28
|
|
|
Service Code
|
MSDRG 638
|
| Min. Negotiated Rate |
$7,370.05 |
| Max. Negotiated Rate |
$25,201.28 |
| Rate for Payer: Aetna Managed Medicare |
$7,370.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,554.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,988.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,239.83
|
| Rate for Payer: Anthem Medicare Advantage |
$7,370.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,370.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,370.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,370.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,807.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,370.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,239.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,370.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,370.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,370.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,370.05
|
| Rate for Payer: NAPHCARE Commercial |
$11,055.08
|
| Rate for Payer: Quartz Medicare Advantage |
$7,370.05
|
| Rate for Payer: The Alliance Commercial |
$25,201.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,370.05
|
| Rate for Payer: United Healthcare PPO |
$14,199.94
|
| Rate for Payer: Wellcare Medicare |
$7,370.05
|
|
|
DIABETES WITH MCC
|
Facility
|
IP
|
$40,405.04
|
|
|
Service Code
|
MSDRG 637
|
| Min. Negotiated Rate |
$11,509.31 |
| Max. Negotiated Rate |
$40,405.04 |
| Rate for Payer: Aetna Managed Medicare |
$11,509.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,347.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,027.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,827.90
|
| Rate for Payer: Anthem Medicare Advantage |
$11,509.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,509.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,509.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,509.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,341.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,509.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,391.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,509.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,509.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,509.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,509.31
|
| Rate for Payer: NAPHCARE Commercial |
$17,263.96
|
| Rate for Payer: Quartz Medicare Advantage |
$11,509.31
|
| Rate for Payer: The Alliance Commercial |
$40,405.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,509.31
|
| Rate for Payer: United Healthcare PPO |
$22,881.89
|
| Rate for Payer: Wellcare Medicare |
$11,509.31
|
|
|
DIABETES WITH NEUROLOGIC MANIFESTATIONS
|
Facility
|
OP
|
$96.96
|
|
|
Service Code
|
EAPG 00712
|
| Min. Negotiated Rate |
$93.23 |
| Max. Negotiated Rate |
$96.96 |
| Rate for Payer: Anthem Medicaid |
$93.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$93.23
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.23
|
| Rate for Payer: Dean Health Medicaid |
$93.23
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$93.23
|
| Rate for Payer: Managed Health Services Medicaid |
$96.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$93.23
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$93.23
|
| Rate for Payer: United Healthcare Medicaid |
$93.23
|
|
|
DIABETES WITH OPHTHALMIC MANIFESTATIONS
|
Facility
|
OP
|
$98.27
|
|
|
Service Code
|
EAPG 00710
|
| Min. Negotiated Rate |
$94.49 |
| Max. Negotiated Rate |
$98.27 |
| Rate for Payer: Anthem Medicaid |
$94.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$94.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$94.49
|
| Rate for Payer: Dean Health Medicaid |
$94.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$94.49
|
| Rate for Payer: Managed Health Services Medicaid |
$98.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$94.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$94.49
|
| Rate for Payer: United Healthcare Medicaid |
$94.49
|
|
|
DIABETES WITH OTHER MANIFESTATIONS & COMPLICATIONS
|
Facility
|
OP
|
$89.10
|
|
|
Service Code
|
EAPG 00711
|
| Min. Negotiated Rate |
$85.67 |
| Max. Negotiated Rate |
$89.10 |
| Rate for Payer: Anthem Medicaid |
$85.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$85.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.67
|
| Rate for Payer: Dean Health Medicaid |
$85.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$85.67
|
| Rate for Payer: Managed Health Services Medicaid |
$89.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.67
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$85.67
|
| Rate for Payer: United Healthcare Medicaid |
$85.67
|
|
|
DIABETES WITHOUT CC/MCC
|
Facility
|
IP
|
$17,544.80
|
|
|
Service Code
|
MSDRG 639
|
| Min. Negotiated Rate |
$5,264.05 |
| Max. Negotiated Rate |
$17,544.80 |
| Rate for Payer: Aetna Managed Medicare |
$5,264.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,554.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,389.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,870.32
|
| Rate for Payer: Anthem Medicare Advantage |
$5,264.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,264.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,264.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,264.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,956.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,264.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,624.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,264.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,264.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,264.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,264.05
|
| Rate for Payer: NAPHCARE Commercial |
$7,896.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,264.05
|
| Rate for Payer: The Alliance Commercial |
$17,544.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,264.05
|
| Rate for Payer: United Healthcare PPO |
$9,828.18
|
| Rate for Payer: Wellcare Medicare |
$5,264.05
|
|
|
DIABETES WITHOUT COMPLICATIONS
|
Facility
|
OP
|
$83.86
|
|
|
Service Code
|
EAPG 00713
|
| Min. Negotiated Rate |
$80.63 |
| Max. Negotiated Rate |
$83.86 |
| Rate for Payer: Anthem Medicaid |
$80.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$80.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.63
|
| Rate for Payer: Dean Health Medicaid |
$80.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$80.63
|
| Rate for Payer: Managed Health Services Medicaid |
$83.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.63
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$80.63
|
| Rate for Payer: United Healthcare Medicaid |
$80.63
|
|
|
DIABETES WITH RENAL MANIFESTATIONS
|
Facility
|
OP
|
$78.62
|
|
|
Service Code
|
EAPG 00714
|
| Min. Negotiated Rate |
$75.59 |
| Max. Negotiated Rate |
$78.62 |
| Rate for Payer: Anthem Medicaid |
$75.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$75.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.59
|
| Rate for Payer: Dean Health Medicaid |
$75.59
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$75.59
|
| Rate for Payer: Managed Health Services Medicaid |
$78.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$75.59
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$75.59
|
| Rate for Payer: United Healthcare Medicaid |
$75.59
|
|
|
DIABETES WITH VASCULAR COMPLICATIONS INCLUDING FOOT AND OTHER SKIN ULCERS
|
Facility
|
OP
|
$89.10
|
|
|
Service Code
|
EAPG 00715
|
| Min. Negotiated Rate |
$85.67 |
| Max. Negotiated Rate |
$89.10 |
| Rate for Payer: Anthem Medicaid |
$85.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$85.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.67
|
| Rate for Payer: Dean Health Medicaid |
$85.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$85.67
|
| Rate for Payer: Managed Health Services Medicaid |
$89.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.67
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$85.67
|
| Rate for Payer: United Healthcare Medicaid |
$85.67
|
|
|
Diabetic Outpatient Class (30 Min) G0109
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
3144169
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$31.16 |
| Max. Negotiated Rate |
$102.38 |
| Rate for Payer: Aetna Commercial |
$100.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.70
|
| Rate for Payer: Aetna Managed Medicare |
$31.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.98
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$102.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.27
|
| Rate for Payer: Health EOS Commercial |
$99.04
|
| Rate for Payer: HFN Commercial |
$102.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.46
|
| Rate for Payer: Multiplan Commercial |
$89.02
|
| Rate for Payer: NAPHCARE Commercial |
$66.77
|
| Rate for Payer: Preferred Network Access Commercial |
$102.38
|
| Rate for Payer: Quartz Beloit One Network |
$54.53
|
| Rate for Payer: Quartz Commercial |
$72.33
|
| Rate for Payer: Quartz Medicare Advantage |
$66.77
|
| Rate for Payer: The Alliance Commercial |
$64.44
|
| Rate for Payer: United Healthcare PPO |
$83.46
|
| Rate for Payer: WEA Trust Commercial |
$61.20
|
| Rate for Payer: WPS Commercial |
$82.42
|
|
|
Diabetic Outpatient Class (30 Min) G0109
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
3144169
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$54.53 |
| Max. Negotiated Rate |
$102.38 |
| Rate for Payer: Aetna Commercial |
$100.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.98
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$102.38
|
| Rate for Payer: Health EOS Commercial |
$99.04
|
| Rate for Payer: HFN Commercial |
$102.38
|
| Rate for Payer: Multiplan Commercial |
$89.02
|
| Rate for Payer: Preferred Network Access Commercial |
$102.38
|
| Rate for Payer: Quartz Beloit One Network |
$54.53
|
| Rate for Payer: Quartz Commercial |
$66.77
|
| Rate for Payer: WEA Trust Commercial |
$61.20
|
| Rate for Payer: WPS Commercial |
$82.42
|
|
|
Diabetic Outpatient Therapy (30 Min) G0108
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
3144168
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$101.41 |
| Max. Negotiated Rate |
$190.40 |
| Rate for Payer: Aetna Commercial |
$186.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.69
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Health EOS Commercial |
$184.19
|
| Rate for Payer: HFN Commercial |
$190.40
|
| Rate for Payer: Multiplan Commercial |
$165.57
|
| Rate for Payer: Preferred Network Access Commercial |
$190.40
|
| Rate for Payer: Quartz Beloit One Network |
$101.41
|
| Rate for Payer: Quartz Commercial |
$124.18
|
| Rate for Payer: WEA Trust Commercial |
$113.83
|
| Rate for Payer: WPS Commercial |
$153.29
|
|
|
Diabetic Outpatient Therapy (30 Min) G0108
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
3144168
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$57.95 |
| Max. Negotiated Rate |
$223.93 |
| Rate for Payer: Aetna Commercial |
$186.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.99
|
| Rate for Payer: Aetna Managed Medicare |
$57.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$134.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$103.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.69
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.82
|
| Rate for Payer: Health EOS Commercial |
$184.19
|
| Rate for Payer: HFN Commercial |
$190.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.22
|
| Rate for Payer: Multiplan Commercial |
$165.57
|
| Rate for Payer: NAPHCARE Commercial |
$124.18
|
| Rate for Payer: Preferred Network Access Commercial |
$190.40
|
| Rate for Payer: Quartz Beloit One Network |
$101.41
|
| Rate for Payer: Quartz Commercial |
$134.52
|
| Rate for Payer: Quartz Medicare Advantage |
$124.18
|
| Rate for Payer: The Alliance Commercial |
$223.93
|
| Rate for Payer: United Healthcare PPO |
$155.22
|
| Rate for Payer: WEA Trust Commercial |
$113.83
|
| Rate for Payer: WPS Commercial |
$153.29
|
|
|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$39.75 |
| Max. Negotiated Rate |
$74.63 |
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.99
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.63
|
| Rate for Payer: Health EOS Commercial |
$72.20
|
| Rate for Payer: HFN Commercial |
$74.63
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$74.63
|
| Rate for Payer: Quartz Beloit One Network |
$39.75
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$60.08
|
|
|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$35.69 |
| Max. Negotiated Rate |
$135.88 |
| Rate for Payer: Aetna Commercial |
$77.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Aetna Managed Medicare |
$47.62
|
| Rate for Payer: Anthem Medicare Advantage |
$47.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.62
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$77.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.62
|
| Rate for Payer: Health EOS Commercial |
$73.82
|
| Rate for Payer: HFN Commercial |
$77.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.62
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: NAPHCARE Commercial |
$71.43
|
| Rate for Payer: Preferred Network Access Commercial |
$77.06
|
| Rate for Payer: Quartz Beloit One Network |
$35.69
|
| Rate for Payer: Quartz Commercial |
$46.24
|
| Rate for Payer: Quartz Medicare Advantage |
$47.62
|
| Rate for Payer: The Alliance Commercial |
$130.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.62
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$83.34
|
|
|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$22.71 |
| Max. Negotiated Rate |
$190.49 |
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Aetna Managed Medicare |
$22.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.77
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.99
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.40
|
| Rate for Payer: Health EOS Commercial |
$72.20
|
| Rate for Payer: HFN Commercial |
$74.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.84
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: NAPHCARE Commercial |
$48.67
|
| Rate for Payer: Preferred Network Access Commercial |
$74.63
|
| Rate for Payer: Quartz Beloit One Network |
$39.75
|
| Rate for Payer: Quartz Commercial |
$52.73
|
| Rate for Payer: Quartz Medicare Advantage |
$48.67
|
| Rate for Payer: The Alliance Commercial |
$190.49
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$60.08
|
|
|
Diab Manage Trn Per Indiv G0108
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
5454715
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.08 |
| Max. Negotiated Rate |
$196.81 |
| Rate for Payer: Aetna Commercial |
$114.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$55.98
|
| Rate for Payer: Anthem Medicare Advantage |
$55.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$55.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$55.98
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$114.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.98
|
| Rate for Payer: Health EOS Commercial |
$109.78
|
| Rate for Payer: HFN Commercial |
$114.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$196.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$55.98
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$83.97
|
| Rate for Payer: Preferred Network Access Commercial |
$114.61
|
| Rate for Payer: Quartz Beloit One Network |
$53.08
|
| Rate for Payer: Quartz Commercial |
$68.76
|
| Rate for Payer: Quartz Medicare Advantage |
$55.98
|
| Rate for Payer: The Alliance Commercial |
$153.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55.98
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$97.97
|
|
|
Diab shoe for density insert A5500
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3133657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
Diab shoe for density insert A5500
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3133657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$271.74 |
| Rate for Payer: Aetna Commercial |
$96.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$94.26
|
| Rate for Payer: Anthem Medicare Advantage |
$94.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$94.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$94.26
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$96.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.26
|
| Rate for Payer: Health EOS Commercial |
$92.75
|
| Rate for Payer: HFN Commercial |
$96.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$94.26
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$141.38
|
| Rate for Payer: Preferred Network Access Commercial |
$96.82
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$58.09
|
| Rate for Payer: Quartz Medicare Advantage |
$94.26
|
| Rate for Payer: The Alliance Commercial |
$259.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.26
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$164.95
|
|
