|
Shigella group B latex
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634168
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$39.52 |
| Rate for Payer: Aetna Commercial |
$39.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$5.39
|
| Rate for Payer: Anthem Medicare Advantage |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.39
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$39.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.39
|
| Rate for Payer: Health EOS Commercial |
$37.86
|
| Rate for Payer: HFN Commercial |
$39.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.39
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$8.08
|
| Rate for Payer: Preferred Network Access Commercial |
$39.52
|
| Rate for Payer: Quartz Beloit One Network |
$18.30
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: Quartz Medicare Advantage |
$5.39
|
| Rate for Payer: The Alliance Commercial |
$21.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.39
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
Shigella group D latex
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634166
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$39.52 |
| Rate for Payer: Aetna Commercial |
$39.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$5.39
|
| Rate for Payer: Anthem Medicare Advantage |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.39
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$39.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.39
|
| Rate for Payer: Health EOS Commercial |
$37.86
|
| Rate for Payer: HFN Commercial |
$39.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.39
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$8.08
|
| Rate for Payer: Preferred Network Access Commercial |
$39.52
|
| Rate for Payer: Quartz Beloit One Network |
$18.30
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: Quartz Medicare Advantage |
$5.39
|
| Rate for Payer: The Alliance Commercial |
$21.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.39
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
Shigella group D latex
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634166
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
Shigella group D latex
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
634166
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$5.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.39
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.39
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.39
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$8.08
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$27.04
|
| Rate for Payer: Quartz Medicare Advantage |
$5.39
|
| Rate for Payer: The Alliance Commercial |
$21.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.39
|
| Rate for Payer: United Healthcare PPO |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: Wellcare Medicare |
$5.39
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
Shingrix Vaccine 90750
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5761623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.26 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna Commercial |
$318.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.41
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$325.31
|
| Rate for Payer: Health EOS Commercial |
$314.70
|
| Rate for Payer: HFN Commercial |
$325.31
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: Preferred Network Access Commercial |
$325.31
|
| Rate for Payer: Quartz Beloit One Network |
$173.26
|
| Rate for Payer: Quartz Commercial |
$212.16
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Shingrix Vaccine 90750
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5761623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.01 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna Commercial |
$318.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Aetna Managed Medicare |
$99.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$229.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$176.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.41
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$325.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.88
|
| Rate for Payer: Health EOS Commercial |
$314.70
|
| Rate for Payer: HFN Commercial |
$325.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.20
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: NAPHCARE Commercial |
$212.16
|
| Rate for Payer: Preferred Network Access Commercial |
$325.31
|
| Rate for Payer: Quartz Beloit One Network |
$173.26
|
| Rate for Payer: Quartz Commercial |
$229.84
|
| Rate for Payer: Quartz Medicare Advantage |
$212.16
|
| Rate for Payer: The Alliance Commercial |
$176.80
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Shingrix Vaccine 90750
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
5761623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.58 |
| Max. Negotiated Rate |
$335.92 |
| Rate for Payer: Aetna Commercial |
$335.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$335.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$224.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$212.16
|
| Rate for Payer: Health EOS Commercial |
$321.78
|
| Rate for Payer: HFN Commercial |
$335.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$252.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$252.15
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: Preferred Network Access Commercial |
$335.92
|
| Rate for Payer: Quartz Beloit One Network |
$155.58
|
| Rate for Payer: Quartz Commercial |
$201.55
|
| Rate for Payer: The Alliance Commercial |
$176.80
|
| Rate for Payer: United Healthcare Medicaid |
$224.13
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
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 |
$58.72 |
| Max. Negotiated Rate |
$377.02 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$70.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$58.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.43
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$151.63
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$164.27
|
| Rate for Payer: Quartz Medicare Advantage |
$151.63
|
| Rate for Payer: The Alliance Commercial |
$377.02
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
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 |
$123.83 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$151.63
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
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 |
$58.72 |
| Max. Negotiated Rate |
$377.02 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$70.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$58.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.43
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$151.63
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$164.27
|
| Rate for Payer: Quartz Medicare Advantage |
$151.63
|
| Rate for Payer: The Alliance Commercial |
$377.02
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
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 |
$123.83 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$151.63
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
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 |
$126.38 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$154.75
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
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 |
$58.72 |
| Max. Negotiated Rate |
$377.02 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Aetna Managed Medicare |
$72.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$58.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.34
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.44
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: NAPHCARE Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$167.65
|
| Rate for Payer: Quartz Medicare Advantage |
$154.75
|
| Rate for Payer: The Alliance Commercial |
$377.02
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
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 |
$123.83 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$151.63
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
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 |
$58.72 |
| Max. Negotiated Rate |
$377.02 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$70.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$58.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.43
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$151.63
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$164.27
|
| Rate for Payer: Quartz Medicare Advantage |
$151.63
|
| Rate for Payer: The Alliance Commercial |
$377.02
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
SHOE DARCO MALE 12.5-14 XLARGE
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2969921
|
|
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
|
|
|
SHOE DARCO MALE 12.5-14 XLARGE
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2969921
|
|
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
|
|
|
SHOE DARCO MALE 6-8 SMALL DS1016-10
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2969918
|
|
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
|
|
|
SHOE DARCO MALE 6-8 SMALL DS1016-10
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2969918
|
|
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
|
|
|
SHOE DARCO MALE 8.5-10 MEDIUM DS1016-12
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
2969919
|
|
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
|
|
|
SHOE DARCO MALE 8.5-10 MEDIUM DS1016-12
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
2969919
|
|
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
|
|
|
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 |
$5.61 |
| 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
|
|
|
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 |
$3.20 |
| Max. Negotiated Rate |
$175.64 |
| 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 |
$18.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.10
|
| 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 |
$175.64
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
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 |
$5.03 |
| Max. Negotiated Rate |
$126.62 |
| Rate for Payer: Aetna Commercial |
$10.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Aetna Managed Medicare |
$43.91
|
| Rate for Payer: Anthem Medicare Advantage |
$43.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.91
|
| Rate for Payer: Cash Price |
$3.30
|
| 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 |
$43.91
|
| Rate for Payer: Health EOS Commercial |
$10.41
|
| Rate for Payer: HFN Commercial |
$10.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$126.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.91
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: NAPHCARE Commercial |
$65.86
|
| 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: Quartz Medicare Advantage |
$43.91
|
| Rate for Payer: The Alliance Commercial |
$120.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.91
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$76.84
|
|
|
SHOEHORN 24 STAINLESS STEEL #2064
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
2970502
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
