|
Shigella group B latex
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634168
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
Shigella group B latex
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634168
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.00
|
| Rate for Payer: Health EOS Commercial |
$36.40
|
| Rate for Payer: HFN Commercial |
$38.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.29
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: Preferred Network Access Commercial |
$38.00
|
| Rate for Payer: Quartz Beloit One Network |
$17.60
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
Shigella group D latex
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634166
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Aetna Managed Medicare |
$5.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.60
|
| Rate for Payer: Anthem Medicaid |
$5.35
|
| Rate for Payer: Anthem Medicare Advantage |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.18
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.38
|
| Rate for Payer: Dean Health Medicaid |
$5.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.18
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.18
|
| Rate for Payer: Managed Health Services Medicaid |
$5.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.18
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$7.77
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.35
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$26.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5.18
|
| Rate for Payer: The Alliance Commercial |
$20.72
|
| Rate for Payer: United Healthcare Medicaid |
$5.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.18
|
| Rate for Payer: United Healthcare PPO |
$30.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: Wellcare Medicare |
$5.18
|
| Rate for Payer: WMAP Medicaid |
$5.35
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
Shigella group D latex
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634166
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
Shigella group D latex
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634166
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.00
|
| Rate for Payer: Health EOS Commercial |
$36.40
|
| Rate for Payer: HFN Commercial |
$38.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.29
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: Preferred Network Access Commercial |
$38.00
|
| Rate for Payer: Quartz Beloit One Network |
$17.60
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
Shingrix Vaccine 90750
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5761623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$312.80 |
| Rate for Payer: Aetna Commercial |
$306.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.20
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$312.80
|
| Rate for Payer: Health EOS Commercial |
$302.60
|
| Rate for Payer: HFN Commercial |
$312.80
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: NAPHCARE Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$312.80
|
| Rate for Payer: Quartz Beloit One Network |
$166.60
|
| Rate for Payer: Quartz Commercial |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Shingrix Vaccine 90750
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5761623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$1,360.00 |
| Rate for Payer: Aetna Commercial |
$306.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Aetna Managed Medicare |
$95.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$221.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$170.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$163.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.20
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$312.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.26
|
| Rate for Payer: Health EOS Commercial |
$302.60
|
| Rate for Payer: HFN Commercial |
$312.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$255.00
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: NAPHCARE Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$312.80
|
| Rate for Payer: Quartz Beloit One Network |
$166.60
|
| Rate for Payer: Quartz Commercial |
$221.00
|
| Rate for Payer: Quartz Medicare Advantage |
$204.00
|
| Rate for Payer: The Alliance Commercial |
$1,360.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Shingrix Vaccine 90750
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5761623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.60 |
| Max. Negotiated Rate |
$323.00 |
| Rate for Payer: Aetna Commercial |
$323.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$198.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$204.00
|
| Rate for Payer: Health EOS Commercial |
$309.40
|
| Rate for Payer: HFN Commercial |
$323.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$242.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.45
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: Preferred Network Access Commercial |
$323.00
|
| Rate for Payer: Quartz Beloit One Network |
$149.60
|
| Rate for Payer: Quartz Commercial |
$193.80
|
| Rate for Payer: The Alliance Commercial |
$170.00
|
| Rate for Payer: United Healthcare Medicaid |
$198.41
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
SHOE DARCO FEMALE 6.5-8 MEDIUM DS1015-12
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
2969922
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$223.56 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$145.80
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
SHOE DARCO FEMALE 6.5-8 MEDIUM DS1015-12
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
2969922
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.46 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Aetna Managed Medicare |
$68.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.98
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$157.95
|
| Rate for Payer: Quartz Medicare Advantage |
$145.80
|
| Rate for Payer: The Alliance Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
SHOE DARCO FEMALE 8.5-10 LARGE DS1015-14
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
2969923
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.46 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Aetna Managed Medicare |
$68.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.98
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$157.95
|
| Rate for Payer: Quartz Medicare Advantage |
$145.80
|
| Rate for Payer: The Alliance Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
SHOE DARCO FEMALE 8.5-10 LARGE DS1015-14
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
2969923
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$223.56 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$145.80
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
SHOE DARCO FEMALE SM DS1015-10
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3065491
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$121.52 |
| Max. Negotiated Rate |
$228.16 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$148.80
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
SHOE DARCO FEMALE SM DS1015-10
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3065491
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.46 |
| Max. Negotiated Rate |
$992.00 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Aetna Managed Medicare |
$69.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.78
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.00
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$161.20
|
| Rate for Payer: Quartz Medicare Advantage |
$148.80
|
| Rate for Payer: The Alliance Commercial |
$992.00
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
SHOE DARCO MALE 10.5-12 LARGE DS1016-14
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
2969920
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.46 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Aetna Managed Medicare |
$68.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.98
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$157.95
|
| Rate for Payer: Quartz Medicare Advantage |
$145.80
|
| Rate for Payer: The Alliance Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
SHOE DARCO MALE 10.5-12 LARGE DS1016-14
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
2969920
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$223.56 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$145.80
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
SHOE DARCO MALE 12.5-14 XLARGE
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2969921
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$144.60
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
SHOE DARCO MALE 12.5-14 XLARGE
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2969921
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.48 |
| Max. Negotiated Rate |
$964.00 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Aetna Managed Medicare |
$67.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.86
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.75
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$156.65
|
| Rate for Payer: Quartz Medicare Advantage |
$144.60
|
| Rate for Payer: The Alliance Commercial |
$964.00
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
SHOE DARCO MALE 6-8 SMALL DS1016-10
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2969918
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$144.60
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
SHOE DARCO MALE 6-8 SMALL DS1016-10
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2969918
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.48 |
| Max. Negotiated Rate |
$964.00 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Aetna Managed Medicare |
$67.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.86
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.75
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$156.65
|
| Rate for Payer: Quartz Medicare Advantage |
$144.60
|
| Rate for Payer: The Alliance Commercial |
$964.00
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
SHOE DARCO MALE 8.5-10 MEDIUM DS1016-12
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2969919
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.48 |
| Max. Negotiated Rate |
$964.00 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Aetna Managed Medicare |
$67.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.86
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.75
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$156.65
|
| Rate for Payer: Quartz Medicare Advantage |
$144.60
|
| Rate for Payer: The Alliance Commercial |
$964.00
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
SHOE DARCO MALE 8.5-10 MEDIUM DS1016-12
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2969919
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$144.60
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Shoe heel new rubber standar L3460
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS L3460
|
| Hospital Charge Code |
3311475
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$6.60
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
Shoe heel new rubber standar L3460
|
Professional
|
Both
|
$11.00
|
|
|
Service Code
|
HCPCS L3460
|
| Hospital Charge Code |
3311475
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$4.84 |
| Max. Negotiated Rate |
$121.75 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.60
|
| Rate for Payer: Health EOS Commercial |
$10.01
|
| Rate for Payer: HFN Commercial |
$10.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.75
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10.45
|
| Rate for Payer: Quartz Beloit One Network |
$4.84
|
| Rate for Payer: Quartz Commercial |
$6.27
|
| Rate for Payer: The Alliance Commercial |
$5.50
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
Shoe heel new rubber standar L3460
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS L3460
|
| Hospital Charge Code |
3311475
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Aetna Managed Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.16
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$7.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6.60
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
