|
PROTECTOR ELBOW LRG W/GEL
|
Facility
|
OP
|
$681.00
|
|
| Hospital Charge Code |
2971537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.31 |
| Max. Negotiated Rate |
$651.58 |
| Rate for Payer: Aetna Commercial |
$637.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$609.09
|
| Rate for Payer: Aetna Managed Medicare |
$198.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$460.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$354.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$339.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$375.37
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cigna Commercial |
$651.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$396.34
|
| Rate for Payer: Health EOS Commercial |
$630.33
|
| Rate for Payer: HFN Commercial |
$651.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$531.18
|
| Rate for Payer: Multiplan Commercial |
$566.59
|
| Rate for Payer: NAPHCARE Commercial |
$424.94
|
| Rate for Payer: Preferred Network Access Commercial |
$651.58
|
| Rate for Payer: Quartz Beloit One Network |
$347.04
|
| Rate for Payer: Quartz Commercial |
$460.36
|
| Rate for Payer: Quartz Medicare Advantage |
$424.94
|
| Rate for Payer: The Alliance Commercial |
$354.12
|
| Rate for Payer: WEA Trust Commercial |
$389.53
|
| Rate for Payer: WPS Commercial |
$524.57
|
|
|
PROTECTOR ELBOW LRG W/GEL
|
Facility
|
IP
|
$681.00
|
|
| Hospital Charge Code |
2971537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$347.04 |
| Max. Negotiated Rate |
$651.58 |
| Rate for Payer: Aetna Commercial |
$637.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$609.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$375.37
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cigna Commercial |
$651.58
|
| Rate for Payer: Health EOS Commercial |
$630.33
|
| Rate for Payer: HFN Commercial |
$651.58
|
| Rate for Payer: Multiplan Commercial |
$566.59
|
| Rate for Payer: Preferred Network Access Commercial |
$651.58
|
| Rate for Payer: Quartz Beloit One Network |
$347.04
|
| Rate for Payer: Quartz Commercial |
$424.94
|
| Rate for Payer: WEA Trust Commercial |
$389.53
|
| Rate for Payer: WPS Commercial |
$524.57
|
|
|
PROTECTOR ELBOW X-LRG W/GEL
|
Facility
|
IP
|
$681.00
|
|
| Hospital Charge Code |
2971538
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$347.04 |
| Max. Negotiated Rate |
$651.58 |
| Rate for Payer: Aetna Commercial |
$637.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$609.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$375.37
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cigna Commercial |
$651.58
|
| Rate for Payer: Health EOS Commercial |
$630.33
|
| Rate for Payer: HFN Commercial |
$651.58
|
| Rate for Payer: Multiplan Commercial |
$566.59
|
| Rate for Payer: Preferred Network Access Commercial |
$651.58
|
| Rate for Payer: Quartz Beloit One Network |
$347.04
|
| Rate for Payer: Quartz Commercial |
$424.94
|
| Rate for Payer: WEA Trust Commercial |
$389.53
|
| Rate for Payer: WPS Commercial |
$524.57
|
|
|
PROTECTOR ELBOW X-LRG W/GEL
|
Facility
|
OP
|
$681.00
|
|
| Hospital Charge Code |
2971538
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.31 |
| Max. Negotiated Rate |
$651.58 |
| Rate for Payer: Aetna Commercial |
$637.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$609.09
|
| Rate for Payer: Aetna Managed Medicare |
$198.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$460.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$354.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$339.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$375.37
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cigna Commercial |
$651.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$396.34
|
| Rate for Payer: Health EOS Commercial |
$630.33
|
| Rate for Payer: HFN Commercial |
$651.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$531.18
|
| Rate for Payer: Multiplan Commercial |
$566.59
|
| Rate for Payer: NAPHCARE Commercial |
$424.94
|
| Rate for Payer: Preferred Network Access Commercial |
$651.58
|
| Rate for Payer: Quartz Beloit One Network |
$347.04
|
| Rate for Payer: Quartz Commercial |
$460.36
|
| Rate for Payer: Quartz Medicare Advantage |
$424.94
|
| Rate for Payer: The Alliance Commercial |
$354.12
|
| Rate for Payer: WEA Trust Commercial |
$389.53
|
| Rate for Payer: WPS Commercial |
$524.57
|
|
|
PROTECTOR EYE OPTI-GARD STERIL #28310
|
Facility
|
IP
|
$160.00
|
|
| Hospital Charge Code |
2972743
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.54 |
| Max. Negotiated Rate |
$153.09 |
| Rate for Payer: Aetna Commercial |
$149.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.19
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$153.09
|
| Rate for Payer: Health EOS Commercial |
$148.10
|
| Rate for Payer: HFN Commercial |
$153.09
|
| Rate for Payer: Multiplan Commercial |
$133.12
|
| Rate for Payer: Preferred Network Access Commercial |
$153.09
|
| Rate for Payer: Quartz Beloit One Network |
$81.54
|
| Rate for Payer: Quartz Commercial |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$91.52
|
| Rate for Payer: WPS Commercial |
$123.25
|
|
|
PROTECTOR EYE OPTI-GARD STERIL #28310
|
Facility
|
OP
|
$160.00
|
|
| Hospital Charge Code |
2972743
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.59 |
| Max. Negotiated Rate |
$153.09 |
| Rate for Payer: Aetna Commercial |
$149.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.10
|
| Rate for Payer: Aetna Managed Medicare |
$46.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$108.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.19
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$153.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.12
|
| Rate for Payer: Health EOS Commercial |
$148.10
|
| Rate for Payer: HFN Commercial |
$153.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.80
|
| Rate for Payer: Multiplan Commercial |
$133.12
|
| Rate for Payer: NAPHCARE Commercial |
$99.84
|
| Rate for Payer: Preferred Network Access Commercial |
$153.09
|
| Rate for Payer: Quartz Beloit One Network |
$81.54
|
| Rate for Payer: Quartz Commercial |
$108.16
|
| Rate for Payer: Quartz Medicare Advantage |
$99.84
|
| Rate for Payer: The Alliance Commercial |
$83.20
|
| Rate for Payer: WEA Trust Commercial |
$91.52
|
| Rate for Payer: WPS Commercial |
$123.25
|
|
|
PROTECTOR HEELBO LARGE #7000-03
|
Facility
|
OP
|
$256.00
|
|
| Hospital Charge Code |
2969612
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$74.55 |
| Max. Negotiated Rate |
$244.94 |
| Rate for Payer: Aetna Commercial |
$239.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.97
|
| Rate for Payer: Aetna Managed Medicare |
$74.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$173.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$133.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$127.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$141.11
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cigna Commercial |
$244.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.99
|
| Rate for Payer: Health EOS Commercial |
$236.95
|
| Rate for Payer: HFN Commercial |
$244.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.68
|
| Rate for Payer: Multiplan Commercial |
$212.99
|
| Rate for Payer: NAPHCARE Commercial |
$159.74
|
| Rate for Payer: Preferred Network Access Commercial |
$244.94
|
| Rate for Payer: Quartz Beloit One Network |
$130.46
|
| Rate for Payer: Quartz Commercial |
$173.06
|
| Rate for Payer: Quartz Medicare Advantage |
$159.74
|
| Rate for Payer: The Alliance Commercial |
$133.12
|
| Rate for Payer: WEA Trust Commercial |
$146.43
|
| Rate for Payer: WPS Commercial |
$197.20
|
|
|
PROTECTOR HEELBO LARGE #7000-03
|
Facility
|
IP
|
$256.00
|
|
| Hospital Charge Code |
2969612
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$130.46 |
| Max. Negotiated Rate |
$244.94 |
| Rate for Payer: Aetna Commercial |
$239.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$141.11
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cigna Commercial |
$244.94
|
| Rate for Payer: Health EOS Commercial |
$236.95
|
| Rate for Payer: HFN Commercial |
$244.94
|
| Rate for Payer: Multiplan Commercial |
$212.99
|
| Rate for Payer: Preferred Network Access Commercial |
$244.94
|
| Rate for Payer: Quartz Beloit One Network |
$130.46
|
| Rate for Payer: Quartz Commercial |
$159.74
|
| Rate for Payer: WEA Trust Commercial |
$146.43
|
| Rate for Payer: WPS Commercial |
$197.20
|
|
|
PROTECTOR HEELBO X-LARGE #081181742
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2969613
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$122.81 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$150.38
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
PROTECTOR HEELBO X-LARGE #081181742
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2969613
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.18 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$70.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$125.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.26
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.98
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$150.38
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$162.92
|
| Rate for Payer: Quartz Medicare Advantage |
$150.38
|
| Rate for Payer: The Alliance Commercial |
$125.32
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
PROTECTOR HEELBO XXL-BEIGE 081181759
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2969654
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$122.81 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$150.38
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
PROTECTOR HEELBO XXL-BEIGE 081181759
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2969654
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.18 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$70.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$125.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.26
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.98
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$150.38
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$162.92
|
| Rate for Payer: Quartz Medicare Advantage |
$150.38
|
| Rate for Payer: The Alliance Commercial |
$125.32
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
PROTECTOR HEEL/ELBOW SMALL
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2970733
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.18 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$70.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$125.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.26
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.98
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$150.38
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$162.92
|
| Rate for Payer: Quartz Medicare Advantage |
$150.38
|
| Rate for Payer: The Alliance Commercial |
$125.32
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
PROTECTOR HEEL/ELBOW SMALL
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2970733
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$122.81 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$150.38
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
Protector heel or elbow E0191
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS E0191
|
| Hospital Charge Code |
4036669
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Aetna Managed Medicare |
$3.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.40
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: NAPHCARE Commercial |
$6.86
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$7.44
|
| Rate for Payer: Quartz Medicare Advantage |
$6.86
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Protector heel or elbow E0191
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS E0191
|
| Hospital Charge Code |
4036669
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$6.86
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Protector heel or elbow E0191
|
Professional
|
Both
|
$11.00
|
|
|
Service Code
|
HCPCS E0191
|
| Hospital Charge Code |
4036669
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$10.87 |
| Rate for Payer: Aetna Commercial |
$10.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.86
|
| Rate for Payer: Health EOS Commercial |
$10.41
|
| Rate for Payer: HFN Commercial |
$10.87
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10.87
|
| Rate for Payer: Quartz Beloit One Network |
$5.03
|
| Rate for Payer: Quartz Commercial |
$6.52
|
| Rate for Payer: The Alliance Commercial |
$5.72
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
PROTECTOR TEETH ADULT #9-3041-03
|
Facility
|
IP
|
$69.00
|
|
| Hospital Charge Code |
2974706
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$66.02 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: Preferred Network Access Commercial |
$66.02
|
| Rate for Payer: Quartz Beloit One Network |
$35.16
|
| Rate for Payer: Quartz Commercial |
$43.06
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
PROTECTOR TEETH ADULT #9-3041-03
|
Facility
|
OP
|
$69.00
|
|
| Hospital Charge Code |
2974706
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.09 |
| Max. Negotiated Rate |
$66.02 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Aetna Managed Medicare |
$20.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.16
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.82
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: NAPHCARE Commercial |
$43.06
|
| Rate for Payer: Preferred Network Access Commercial |
$66.02
|
| Rate for Payer: Quartz Beloit One Network |
$35.16
|
| Rate for Payer: Quartz Commercial |
$46.64
|
| Rate for Payer: Quartz Medicare Advantage |
$43.06
|
| Rate for Payer: The Alliance Commercial |
$35.88
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
ProtÈgÈ 10mm x 20mm 120cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 10mm x 20mm 120cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 10mm x 20mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 10mm x 20mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 10mm x 20mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 10mm x 20mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
