|
ORTHO GLASS SPLINT 4 x 15' #OG-4L2
|
Facility
|
OP
|
$1,160.00
|
|
| Hospital Charge Code |
2969538
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$324.80 |
| Max. Negotiated Rate |
$4,640.00 |
| Rate for Payer: Aetna Commercial |
$1,044.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.60
|
| Rate for Payer: Aetna Managed Medicare |
$324.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$754.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$580.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$556.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.80
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,067.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$649.14
|
| Rate for Payer: Health EOS Commercial |
$1,032.40
|
| Rate for Payer: HFN Commercial |
$1,067.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$870.00
|
| Rate for Payer: Multiplan Commercial |
$928.00
|
| Rate for Payer: NAPHCARE Commercial |
$696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,067.20
|
| Rate for Payer: Quartz Beloit One Network |
$568.40
|
| Rate for Payer: Quartz Commercial |
$754.00
|
| Rate for Payer: Quartz Medicare Advantage |
$696.00
|
| Rate for Payer: The Alliance Commercial |
$4,640.00
|
| Rate for Payer: WEA Trust Commercial |
$638.00
|
| Rate for Payer: WPS Commercial |
$859.21
|
|
|
ORTHO GLASS SPLINT 4 x 15' #OG-4L2
|
Facility
|
IP
|
$1,160.00
|
|
| Hospital Charge Code |
2969538
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$568.40 |
| Max. Negotiated Rate |
$1,067.20 |
| Rate for Payer: Aetna Commercial |
$1,044.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.80
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,067.20
|
| Rate for Payer: Health EOS Commercial |
$1,032.40
|
| Rate for Payer: HFN Commercial |
$1,067.20
|
| Rate for Payer: Multiplan Commercial |
$928.00
|
| Rate for Payer: NAPHCARE Commercial |
$696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,067.20
|
| Rate for Payer: Quartz Beloit One Network |
$568.40
|
| Rate for Payer: Quartz Commercial |
$696.00
|
| Rate for Payer: WEA Trust Commercial |
$638.00
|
| Rate for Payer: WPS Commercial |
$859.21
|
|
|
Orthopedic mens shoes dpth L3221
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS L3221
|
| Hospital Charge Code |
4538608
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$38.28 |
| Max. Negotiated Rate |
$301.67 |
| Rate for Payer: Aetna Commercial |
$82.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$82.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.20
|
| Rate for Payer: Health EOS Commercial |
$79.17
|
| Rate for Payer: HFN Commercial |
$82.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$301.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$301.67
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: Preferred Network Access Commercial |
$82.65
|
| Rate for Payer: Quartz Beloit One Network |
$38.28
|
| Rate for Payer: Quartz Commercial |
$49.59
|
| Rate for Payer: The Alliance Commercial |
$43.50
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
Orthopedic mens shoes dpth L3221
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS L3221
|
| Hospital Charge Code |
4538608
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$52.20
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
Orthopedic mens shoes dpth L3221
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS L3221
|
| Hospital Charge Code |
4538608
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$24.36 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Aetna Managed Medicare |
$24.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$56.55
|
| Rate for Payer: Quartz Medicare Advantage |
$52.20
|
| Rate for Payer: The Alliance Commercial |
$348.00
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
ORTHOSIS DEPRESSION #ACM-9202
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2970537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$38.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$82.80
|
| Rate for Payer: The Alliance Commercial |
$552.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
ORTHOSIS DEPRESSION #ACM-9202
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2970537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
ORTHOSIS THERAPLUS UNIVERSAL
|
Facility
|
IP
|
$1,010.00
|
|
| Hospital Charge Code |
2971812
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$494.90 |
| Max. Negotiated Rate |
$929.20 |
| Rate for Payer: Aetna Commercial |
$909.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$868.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$535.30
|
| Rate for Payer: Cash Price |
$303.00
|
| Rate for Payer: Cigna Commercial |
$929.20
|
| Rate for Payer: Health EOS Commercial |
$898.90
|
| Rate for Payer: HFN Commercial |
$929.20
|
| Rate for Payer: Multiplan Commercial |
$808.00
|
| Rate for Payer: NAPHCARE Commercial |
$606.00
|
| Rate for Payer: Preferred Network Access Commercial |
$929.20
|
| Rate for Payer: Quartz Beloit One Network |
$494.90
|
| Rate for Payer: Quartz Commercial |
$606.00
|
| Rate for Payer: WEA Trust Commercial |
$555.50
|
| Rate for Payer: WPS Commercial |
$748.11
|
|
|
ORTHOSIS THERAPLUS UNIVERSAL
|
Facility
|
OP
|
$1,010.00
|
|
| Hospital Charge Code |
2971812
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$282.80 |
| Max. Negotiated Rate |
$4,040.00 |
| Rate for Payer: Aetna Commercial |
$909.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$868.60
|
| Rate for Payer: Aetna Managed Medicare |
$282.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$656.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$505.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$484.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$535.30
|
| Rate for Payer: Cash Price |
$303.00
|
| Rate for Payer: Cigna Commercial |
$929.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$565.20
|
| Rate for Payer: Health EOS Commercial |
$898.90
|
| Rate for Payer: HFN Commercial |
$929.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$757.50
|
| Rate for Payer: Multiplan Commercial |
$808.00
|
| Rate for Payer: NAPHCARE Commercial |
$606.00
|
| Rate for Payer: Preferred Network Access Commercial |
$929.20
|
| Rate for Payer: Quartz Beloit One Network |
$494.90
|
| Rate for Payer: Quartz Commercial |
$656.50
|
| Rate for Payer: Quartz Medicare Advantage |
$606.00
|
| Rate for Payer: The Alliance Commercial |
$4,040.00
|
| Rate for Payer: WEA Trust Commercial |
$555.50
|
| Rate for Payer: WPS Commercial |
$748.11
|
|
|
ORTHOTICS CUSTOM FOOT
|
Facility
|
IP
|
$1,846.00
|
|
| Hospital Charge Code |
2974106
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$904.54 |
| Max. Negotiated Rate |
$1,698.32 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,107.60
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
ORTHOTICS CUSTOM FOOT
|
Facility
|
OP
|
$1,846.00
|
|
| Hospital Charge Code |
2974106
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$516.88 |
| Max. Negotiated Rate |
$7,384.00 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Aetna Managed Medicare |
$516.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,199.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$923.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$886.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,033.02
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,384.50
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,199.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,107.60
|
| Rate for Payer: The Alliance Commercial |
$7,384.00
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
Orthotics Fit And Training
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
CPT 97760
|
| Hospital Charge Code |
1188844
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.04 |
| Max. Negotiated Rate |
$169.05 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.60
|
| Rate for Payer: Health EOS Commercial |
$60.06
|
| Rate for Payer: HFN Commercial |
$62.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$169.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$169.05
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: Preferred Network Access Commercial |
$62.70
|
| Rate for Payer: Quartz Beloit One Network |
$29.04
|
| Rate for Payer: Quartz Commercial |
$37.62
|
| Rate for Payer: The Alliance Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
|
Orthotic Training Charges PT
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 97760 GP
|
| Hospital Charge Code |
5328629
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$122.99 |
| Max. Negotiated Rate |
$230.92 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$150.60
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
Orthotic Training Charges PT
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 97760 GP
|
| Hospital Charge Code |
5328629
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$70.28 |
| Max. Negotiated Rate |
$1,004.00 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Aetna Managed Medicare |
$70.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.46
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$163.15
|
| Rate for Payer: Quartz Medicare Advantage |
$150.60
|
| Rate for Payer: The Alliance Commercial |
$1,004.00
|
| Rate for Payer: United Healthcare PPO |
$188.25
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
Orthovisc Charge
|
Professional
|
Both
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5587403
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.64 |
| Max. Negotiated Rate |
$1,079.20 |
| Rate for Payer: Aetna Commercial |
$1,079.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,079.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$130.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.56
|
| Rate for Payer: Health EOS Commercial |
$1,033.76
|
| Rate for Payer: HFN Commercial |
$1,079.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$191.99
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,079.20
|
| Rate for Payer: Quartz Beloit One Network |
$499.84
|
| Rate for Payer: Quartz Commercial |
$647.52
|
| Rate for Payer: The Alliance Commercial |
$568.00
|
| Rate for Payer: United Healthcare Medicaid |
$130.64
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$328.90
|
|
|
Orthovisc Charge
|
Facility
|
IP
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5587403
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$556.64 |
| Max. Negotiated Rate |
$1,045.12 |
| Rate for Payer: Aetna Commercial |
$1,022.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.08
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,045.12
|
| Rate for Payer: Health EOS Commercial |
$1,011.04
|
| Rate for Payer: HFN Commercial |
$1,045.12
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: NAPHCARE Commercial |
$681.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.12
|
| Rate for Payer: Quartz Beloit One Network |
$556.64
|
| Rate for Payer: Quartz Commercial |
$681.60
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$841.44
|
|
|
Orthovisc Charge
|
Facility
|
OP
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5587403
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.64 |
| Max. Negotiated Rate |
$1,045.12 |
| Rate for Payer: Aetna Commercial |
$1,022.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Aetna Managed Medicare |
$130.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$738.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$545.28
|
| Rate for Payer: Anthem Medicare Advantage |
$130.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.64
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,045.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.64
|
| Rate for Payer: Health EOS Commercial |
$1,011.04
|
| Rate for Payer: HFN Commercial |
$1,045.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$485.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.64
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.96
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.12
|
| Rate for Payer: Quartz Beloit One Network |
$556.64
|
| Rate for Payer: Quartz Commercial |
$738.40
|
| Rate for Payer: Quartz Medicare Advantage |
$130.64
|
| Rate for Payer: The Alliance Commercial |
$522.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.64
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: Wellcare Medicare |
$130.64
|
| Rate for Payer: WPS Commercial |
$328.90
|
|
|
Orthovisc Inj Per Dose J7324
|
Facility
|
OP
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5586193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.64 |
| Max. Negotiated Rate |
$1,045.12 |
| Rate for Payer: Aetna Commercial |
$1,022.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Aetna Managed Medicare |
$130.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$738.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$545.28
|
| Rate for Payer: Anthem Medicare Advantage |
$130.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.64
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,045.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.64
|
| Rate for Payer: Health EOS Commercial |
$1,011.04
|
| Rate for Payer: HFN Commercial |
$1,045.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$485.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.64
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.96
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.12
|
| Rate for Payer: Quartz Beloit One Network |
$556.64
|
| Rate for Payer: Quartz Commercial |
$738.40
|
| Rate for Payer: Quartz Medicare Advantage |
$130.64
|
| Rate for Payer: The Alliance Commercial |
$522.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.64
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: Wellcare Medicare |
$130.64
|
| Rate for Payer: WPS Commercial |
$328.90
|
|
|
Orthovisc Inj Per Dose J7324
|
Professional
|
Both
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5586193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.64 |
| Max. Negotiated Rate |
$1,079.20 |
| Rate for Payer: Aetna Commercial |
$1,079.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,079.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$130.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.56
|
| Rate for Payer: Health EOS Commercial |
$1,033.76
|
| Rate for Payer: HFN Commercial |
$1,079.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$191.99
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,079.20
|
| Rate for Payer: Quartz Beloit One Network |
$499.84
|
| Rate for Payer: Quartz Commercial |
$647.52
|
| Rate for Payer: The Alliance Commercial |
$568.00
|
| Rate for Payer: United Healthcare Medicaid |
$130.64
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$328.90
|
|
|
Orthovisc Inj Per Dose J7324
|
Facility
|
IP
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5586193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$556.64 |
| Max. Negotiated Rate |
$1,045.12 |
| Rate for Payer: Aetna Commercial |
$1,022.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.08
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,045.12
|
| Rate for Payer: Health EOS Commercial |
$1,011.04
|
| Rate for Payer: HFN Commercial |
$1,045.12
|
| Rate for Payer: Multiplan Commercial |
$908.80
|
| Rate for Payer: NAPHCARE Commercial |
$681.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.12
|
| Rate for Payer: Quartz Beloit One Network |
$556.64
|
| Rate for Payer: Quartz Commercial |
$681.60
|
| Rate for Payer: WEA Trust Commercial |
$624.80
|
| Rate for Payer: WPS Commercial |
$841.44
|
|
|
OSCILLATING TRACKING TEST 92545
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
CPT 92545
|
| Hospital Charge Code |
3015335
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.40
|
| Rate for Payer: Health EOS Commercial |
$44.59
|
| Rate for Payer: HFN Commercial |
$46.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: Preferred Network Access Commercial |
$46.55
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$27.93
|
| Rate for Payer: The Alliance Commercial |
$24.50
|
| Rate for Payer: United Healthcare Medicaid |
$20.30
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Osmolality
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
633791
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Osmolality
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
633791
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.33 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.00
|
| Rate for Payer: Health EOS Commercial |
$109.20
|
| Rate for Payer: HFN Commercial |
$114.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.33
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$114.00
|
| Rate for Payer: Quartz Beloit One Network |
$52.80
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Osmolality
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
633791
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Aetna Managed Medicare |
$6.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.57
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.97
|
| Rate for Payer: Anthem Medicaid |
$6.83
|
| Rate for Payer: Anthem Medicare Advantage |
$6.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.61
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.15
|
| Rate for Payer: Dean Health Medicaid |
$6.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.61
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.61
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.61
|
| Rate for Payer: Managed Health Services Medicaid |
$7.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.61
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$9.92
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6.83
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: Quartz Medicare Advantage |
$6.61
|
| Rate for Payer: The Alliance Commercial |
$26.44
|
| Rate for Payer: United Healthcare Medicaid |
$6.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.61
|
| Rate for Payer: United Healthcare PPO |
$90.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: Wellcare Medicare |
$6.61
|
| Rate for Payer: WMAP Medicaid |
$6.83
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Osmolality BF to Mayo
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
4619092
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.33 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Aetna Commercial |
$121.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.80
|
| Rate for Payer: Health EOS Commercial |
$116.48
|
| Rate for Payer: HFN Commercial |
$121.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.33
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: Preferred Network Access Commercial |
$121.60
|
| Rate for Payer: Quartz Beloit One Network |
$56.32
|
| Rate for Payer: Quartz Commercial |
$72.96
|
| Rate for Payer: The Alliance Commercial |
$64.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
