|
Afo multiligamentus ankle su L1906
|
Facility
OP
|
$48.00
|
|
|
Service Code
|
HCPCS L1906
|
| Hospital Charge Code |
3898157
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.86
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Afo plastic molded w/ankle j L1970
|
Facility
OP
|
$1,725.00
|
|
|
Service Code
|
HCPCS L1970
|
| Hospital Charge Code |
4075995
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$369.06 |
| Max. Negotiated Rate |
$6,900.00 |
| Rate for Payer: Aetna Commercial |
$1,552.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,483.50
|
| Rate for Payer: Aetna Managed Medicare |
$483.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$369.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$369.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$914.25
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$1,587.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$965.31
|
| Rate for Payer: Health EOS Commercial |
$1,535.25
|
| Rate for Payer: HFN Commercial |
$1,587.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,293.75
|
| Rate for Payer: Multiplan Commercial |
$1,380.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,035.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,587.00
|
| Rate for Payer: Quartz Beloit One Network |
$845.25
|
| Rate for Payer: Quartz Commercial |
$1,121.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,035.00
|
| Rate for Payer: The Alliance Commercial |
$6,900.00
|
| Rate for Payer: WEA Trust Commercial |
$948.75
|
| Rate for Payer: WPS Commercial |
$1,277.71
|
|
|
Afo plastic molded w/ankle j L1970
|
Professional
|
$1,725.00
|
|
|
Service Code
|
HCPCS L1970
|
| Hospital Charge Code |
4075995
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$759.00 |
| Max. Negotiated Rate |
$2,452.57 |
| Rate for Payer: Aetna Commercial |
$1,638.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,483.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$1,638.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$862.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,035.00
|
| Rate for Payer: Health EOS Commercial |
$1,569.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,452.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,452.57
|
| Rate for Payer: Multiplan Commercial |
$1,380.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,638.75
|
| Rate for Payer: Quartz Beloit One Network |
$759.00
|
| Rate for Payer: Quartz Commercial |
$983.25
|
| Rate for Payer: The Alliance Commercial |
$862.50
|
| Rate for Payer: WEA Trust Commercial |
$948.75
|
| Rate for Payer: WPS Commercial |
$1,277.71
|
|
|
Afo plastic molded w/ankle j L1970
|
Facility
IP
|
$1,725.00
|
|
|
Service Code
|
HCPCS L1970
|
| Hospital Charge Code |
4075995
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$845.25 |
| Max. Negotiated Rate |
$1,587.00 |
| Rate for Payer: Aetna Commercial |
$1,552.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$914.25
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$1,587.00
|
| Rate for Payer: Health EOS Commercial |
$1,535.25
|
| Rate for Payer: HFN Commercial |
$1,587.00
|
| Rate for Payer: Multiplan Commercial |
$1,380.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,035.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,587.00
|
| Rate for Payer: Quartz Beloit One Network |
$845.25
|
| Rate for Payer: Quartz Commercial |
$1,035.00
|
| Rate for Payer: WEA Trust Commercial |
$948.75
|
| Rate for Payer: WPS Commercial |
$1,277.71
|
|
|
AFO PRESSURE RELIEF
|
Facility
IP
|
$3,049.00
|
|
| Hospital Charge Code |
2974156
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,494.01 |
| Max. Negotiated Rate |
$2,805.08 |
| Rate for Payer: Aetna Commercial |
$2,744.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,615.97
|
| Rate for Payer: Cash Price |
$914.70
|
| Rate for Payer: Cigna Commercial |
$2,805.08
|
| Rate for Payer: Health EOS Commercial |
$2,713.61
|
| Rate for Payer: HFN Commercial |
$2,805.08
|
| Rate for Payer: Multiplan Commercial |
$2,439.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,829.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,805.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,494.01
|
| Rate for Payer: Quartz Commercial |
$1,829.40
|
| Rate for Payer: WEA Trust Commercial |
$1,676.95
|
| Rate for Payer: WPS Commercial |
$2,258.39
|
|
|
AFO PRESSURE RELIEF
|
Facility
OP
|
$3,049.00
|
|
| Hospital Charge Code |
2974156
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$853.72 |
| Max. Negotiated Rate |
$12,196.00 |
| Rate for Payer: Aetna Commercial |
$2,744.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,622.14
|
| Rate for Payer: Aetna Managed Medicare |
$853.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,981.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,524.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,463.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,615.97
|
| Rate for Payer: Cash Price |
$914.70
|
| Rate for Payer: Cigna Commercial |
$2,805.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,706.22
|
| Rate for Payer: Health EOS Commercial |
$2,713.61
|
| Rate for Payer: HFN Commercial |
$2,805.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,286.75
|
| Rate for Payer: Multiplan Commercial |
$2,439.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,829.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,805.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,494.01
|
| Rate for Payer: Quartz Commercial |
$1,981.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,829.40
|
| Rate for Payer: The Alliance Commercial |
$12,196.00
|
| Rate for Payer: WEA Trust Commercial |
$1,676.95
|
| Rate for Payer: WPS Commercial |
$2,258.39
|
|
|
AFO, RIGID ANT TIBIAL SECTION, TOTAL CARBON FIBER/EQUAL MTRIAL, PREFAB, INCL FITTING & ADJS- L1932
|
Professional
|
$1,092.00
|
|
|
Service Code
|
HCPCS L1932
|
| Hospital Charge Code |
6195786
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$480.48 |
| Max. Negotiated Rate |
$3,162.00 |
| Rate for Payer: Aetna Commercial |
$1,037.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,037.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$546.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$655.20
|
| Rate for Payer: Health EOS Commercial |
$993.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,162.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,162.00
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.40
|
| Rate for Payer: Quartz Beloit One Network |
$480.48
|
| Rate for Payer: Quartz Commercial |
$622.44
|
| Rate for Payer: The Alliance Commercial |
$546.00
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
AFO, RIGID ANT TIBIAL SECTION, TOTAL CARBON FIBER/EQUAL MTRIAL, PREFAB, INCL FITTING & ADJS- L1932
|
Facility
IP
|
$1,092.00
|
|
|
Service Code
|
HCPCS L1932
|
| Hospital Charge Code |
6195786
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$535.08 |
| Max. Negotiated Rate |
$1,004.64 |
| Rate for Payer: Aetna Commercial |
$982.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$578.76
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,004.64
|
| Rate for Payer: Health EOS Commercial |
$971.88
|
| Rate for Payer: HFN Commercial |
$1,004.64
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: NAPHCARE Commercial |
$655.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,004.64
|
| Rate for Payer: Quartz Beloit One Network |
$535.08
|
| Rate for Payer: Quartz Commercial |
$655.20
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
AFO, RIGID ANT TIBIAL SECTION, TOTAL CARBON FIBER/EQUAL MTRIAL, PREFAB, INCL FITTING & ADJS- L1932
|
Facility
OP
|
$1,092.00
|
|
|
Service Code
|
HCPCS L1932
|
| Hospital Charge Code |
6195786
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$305.76 |
| Max. Negotiated Rate |
$4,368.00 |
| Rate for Payer: Aetna Commercial |
$982.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$939.12
|
| Rate for Payer: Aetna Managed Medicare |
$305.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$404.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$404.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$404.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$578.76
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,004.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$611.08
|
| Rate for Payer: Health EOS Commercial |
$971.88
|
| Rate for Payer: HFN Commercial |
$1,004.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$819.00
|
| Rate for Payer: Multiplan Commercial |
$873.60
|
| Rate for Payer: NAPHCARE Commercial |
$655.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,004.64
|
| Rate for Payer: Quartz Beloit One Network |
$535.08
|
| Rate for Payer: Quartz Commercial |
$709.80
|
| Rate for Payer: Quartz Medicare Advantage |
$655.20
|
| Rate for Payer: The Alliance Commercial |
$4,368.00
|
| Rate for Payer: WEA Trust Commercial |
$600.60
|
| Rate for Payer: WPS Commercial |
$808.84
|
|
|
Afo sing bar clasp attach sh L1910
|
Facility
IP
|
$82.00
|
|
|
Service Code
|
HCPCS L1910
|
| Hospital Charge Code |
4548690
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Afo sing bar clasp attach sh L1910
|
Professional
|
$82.00
|
|
|
Service Code
|
HCPCS L1910
|
| Hospital Charge Code |
4548690
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$36.08 |
| Max. Negotiated Rate |
$993.73 |
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$77.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.20
|
| Rate for Payer: Health EOS Commercial |
$74.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$993.73
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: Preferred Network Access Commercial |
$77.90
|
| Rate for Payer: Quartz Beloit One Network |
$36.08
|
| Rate for Payer: Quartz Commercial |
$46.74
|
| Rate for Payer: The Alliance Commercial |
$41.00
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Afo sing bar clasp attach sh L1910
|
Facility
OP
|
$82.00
|
|
|
Service Code
|
HCPCS L1910
|
| Hospital Charge Code |
4548690
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$22.96 |
| Max. Negotiated Rate |
$328.00 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$22.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$168.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$168.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$168.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.89
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.50
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$53.30
|
| Rate for Payer: Quartz Medicare Advantage |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$328.00
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Afo sing solid stirrup calf L1980
|
Professional
|
$974.00
|
|
|
Service Code
|
HCPCS L1980
|
| Hospital Charge Code |
4526616
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$428.56 |
| Max. Negotiated Rate |
$1,430.74 |
| Rate for Payer: Cigna Commercial |
$925.30
|
| Rate for Payer: Aetna Commercial |
$925.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$837.64
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$487.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$584.40
|
| Rate for Payer: Health EOS Commercial |
$886.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,430.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,430.74
|
| Rate for Payer: Multiplan Commercial |
$779.20
|
| Rate for Payer: Preferred Network Access Commercial |
$925.30
|
| Rate for Payer: Quartz Beloit One Network |
$428.56
|
| Rate for Payer: Quartz Commercial |
$555.18
|
| Rate for Payer: The Alliance Commercial |
$487.00
|
| Rate for Payer: WEA Trust Commercial |
$535.70
|
| Rate for Payer: WPS Commercial |
$721.44
|
|
|
Afo sing solid stirrup calf L1980
|
Facility
OP
|
$974.00
|
|
|
Service Code
|
HCPCS L1980
|
| Hospital Charge Code |
4526616
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$230.93 |
| Max. Negotiated Rate |
$3,896.00 |
| Rate for Payer: Aetna Commercial |
$876.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$837.64
|
| Rate for Payer: Aetna Managed Medicare |
$272.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$230.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$230.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$516.22
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$896.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$545.05
|
| Rate for Payer: Health EOS Commercial |
$866.86
|
| Rate for Payer: HFN Commercial |
$896.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$730.50
|
| Rate for Payer: Multiplan Commercial |
$779.20
|
| Rate for Payer: NAPHCARE Commercial |
$584.40
|
| Rate for Payer: Preferred Network Access Commercial |
$896.08
|
| Rate for Payer: Quartz Beloit One Network |
$477.26
|
| Rate for Payer: Quartz Commercial |
$633.10
|
| Rate for Payer: Quartz Medicare Advantage |
$584.40
|
| Rate for Payer: The Alliance Commercial |
$3,896.00
|
| Rate for Payer: WEA Trust Commercial |
$535.70
|
| Rate for Payer: WPS Commercial |
$721.44
|
|
|
Afo sing solid stirrup calf L1980
|
Facility
IP
|
$974.00
|
|
|
Service Code
|
HCPCS L1980
|
| Hospital Charge Code |
4526616
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$477.26 |
| Max. Negotiated Rate |
$896.08 |
| Rate for Payer: Aetna Commercial |
$876.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$516.22
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$896.08
|
| Rate for Payer: Health EOS Commercial |
$866.86
|
| Rate for Payer: HFN Commercial |
$896.08
|
| Rate for Payer: Multiplan Commercial |
$779.20
|
| Rate for Payer: NAPHCARE Commercial |
$584.40
|
| Rate for Payer: Preferred Network Access Commercial |
$896.08
|
| Rate for Payer: Quartz Beloit One Network |
$477.26
|
| Rate for Payer: Quartz Commercial |
$584.40
|
| Rate for Payer: WEA Trust Commercial |
$535.70
|
| Rate for Payer: WPS Commercial |
$721.44
|
|
|
Afo sing upright w/adjust s L1920
|
Professional
|
$1,104.00
|
|
|
Service Code
|
HCPCS L1920
|
| Hospital Charge Code |
4308927
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$485.76 |
| Max. Negotiated Rate |
$1,455.67 |
| Rate for Payer: Aetna Commercial |
$1,048.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$949.44
|
| Rate for Payer: Cash Price |
$331.20
|
| Rate for Payer: Cash Price |
$331.20
|
| Rate for Payer: Cigna Commercial |
$1,048.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$552.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$662.40
|
| Rate for Payer: Health EOS Commercial |
$1,004.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,455.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,455.67
|
| Rate for Payer: Multiplan Commercial |
$883.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,048.80
|
| Rate for Payer: Quartz Beloit One Network |
$485.76
|
| Rate for Payer: Quartz Commercial |
$629.28
|
| Rate for Payer: The Alliance Commercial |
$552.00
|
| Rate for Payer: WEA Trust Commercial |
$607.20
|
| Rate for Payer: WPS Commercial |
$817.73
|
|
|
Afo sing upright w/adjust s L1920
|
Facility
OP
|
$1,104.00
|
|
|
Service Code
|
HCPCS L1920
|
| Hospital Charge Code |
4308927
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$212.74 |
| Max. Negotiated Rate |
$4,416.00 |
| Rate for Payer: Aetna Commercial |
$993.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$949.44
|
| Rate for Payer: Aetna Managed Medicare |
$309.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$212.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$212.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$212.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$585.12
|
| Rate for Payer: Cash Price |
$331.20
|
| Rate for Payer: Cash Price |
$331.20
|
| Rate for Payer: Cigna Commercial |
$1,015.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$617.80
|
| Rate for Payer: Health EOS Commercial |
$982.56
|
| Rate for Payer: HFN Commercial |
$1,015.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$828.00
|
| Rate for Payer: Multiplan Commercial |
$883.20
|
| Rate for Payer: NAPHCARE Commercial |
$662.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,015.68
|
| Rate for Payer: Quartz Beloit One Network |
$540.96
|
| Rate for Payer: Quartz Commercial |
$717.60
|
| Rate for Payer: Quartz Medicare Advantage |
$662.40
|
| Rate for Payer: The Alliance Commercial |
$4,416.00
|
| Rate for Payer: WEA Trust Commercial |
$607.20
|
| Rate for Payer: WPS Commercial |
$817.73
|
|
|
Afo sing upright w/adjust s L1920
|
Facility
IP
|
$1,104.00
|
|
|
Service Code
|
HCPCS L1920
|
| Hospital Charge Code |
4308927
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$540.96 |
| Max. Negotiated Rate |
$1,015.68 |
| Rate for Payer: Aetna Commercial |
$993.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$585.12
|
| Rate for Payer: Cash Price |
$331.20
|
| Rate for Payer: Cigna Commercial |
$1,015.68
|
| Rate for Payer: Health EOS Commercial |
$982.56
|
| Rate for Payer: HFN Commercial |
$1,015.68
|
| Rate for Payer: Multiplan Commercial |
$883.20
|
| Rate for Payer: NAPHCARE Commercial |
$662.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,015.68
|
| Rate for Payer: Quartz Beloit One Network |
$540.96
|
| Rate for Payer: Quartz Commercial |
$662.40
|
| Rate for Payer: WEA Trust Commercial |
$607.20
|
| Rate for Payer: WPS Commercial |
$817.73
|
|
|
Afo w/ankle joint, prefab L1971
|
Facility
IP
|
$1,181.00
|
|
|
Service Code
|
HCPCS L1971
|
| Hospital Charge Code |
5288724
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$578.69 |
| Max. Negotiated Rate |
$1,086.52 |
| Rate for Payer: Aetna Commercial |
$1,062.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.93
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cigna Commercial |
$1,086.52
|
| Rate for Payer: Health EOS Commercial |
$1,051.09
|
| Rate for Payer: HFN Commercial |
$1,086.52
|
| Rate for Payer: Multiplan Commercial |
$944.80
|
| Rate for Payer: NAPHCARE Commercial |
$708.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.52
|
| Rate for Payer: Quartz Beloit One Network |
$578.69
|
| Rate for Payer: Quartz Commercial |
$708.60
|
| Rate for Payer: WEA Trust Commercial |
$649.55
|
| Rate for Payer: WPS Commercial |
$874.77
|
|
|
Afo w/ankle joint, prefab L1971
|
Facility
OP
|
$1,181.00
|
|
|
Service Code
|
HCPCS L1971
|
| Hospital Charge Code |
5288724
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$330.68 |
| Max. Negotiated Rate |
$4,724.00 |
| Rate for Payer: Aetna Commercial |
$1,062.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.66
|
| Rate for Payer: Aetna Managed Medicare |
$330.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$369.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$369.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.93
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cigna Commercial |
$1,086.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$660.89
|
| Rate for Payer: Health EOS Commercial |
$1,051.09
|
| Rate for Payer: HFN Commercial |
$1,086.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$885.75
|
| Rate for Payer: Multiplan Commercial |
$944.80
|
| Rate for Payer: NAPHCARE Commercial |
$708.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.52
|
| Rate for Payer: Quartz Beloit One Network |
$578.69
|
| Rate for Payer: Quartz Commercial |
$767.65
|
| Rate for Payer: Quartz Medicare Advantage |
$708.60
|
| Rate for Payer: The Alliance Commercial |
$4,724.00
|
| Rate for Payer: WEA Trust Commercial |
$649.55
|
| Rate for Payer: WPS Commercial |
$874.77
|
|
|
Afo w/ankle joint, prefab L1971
|
Professional
|
$1,181.00
|
|
|
Service Code
|
HCPCS L1971
|
| Hospital Charge Code |
5288724
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$519.64 |
| Max. Negotiated Rate |
$1,661.04 |
| Rate for Payer: Aetna Commercial |
$1,121.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.66
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cigna Commercial |
$1,121.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$590.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$708.60
|
| Rate for Payer: Health EOS Commercial |
$1,074.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,661.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,661.04
|
| Rate for Payer: Multiplan Commercial |
$944.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,121.95
|
| Rate for Payer: Quartz Beloit One Network |
$519.64
|
| Rate for Payer: Quartz Commercial |
$673.17
|
| Rate for Payer: The Alliance Commercial |
$590.50
|
| Rate for Payer: WEA Trust Commercial |
$649.55
|
| Rate for Payer: WPS Commercial |
$874.77
|
|
|
AFP Maternal / 5059
|
Facility
IP
|
$245.00
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
977774
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$120.05 |
| Max. Negotiated Rate |
$225.40 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$147.00
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
AFP Maternal / 5059
|
Facility
OP
|
$245.00
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
977774
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$980.00 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Aetna Managed Medicare |
$16.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.84
|
| Rate for Payer: Anthem Medicaid |
$17.33
|
| Rate for Payer: Anthem Medicare Advantage |
$16.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.77
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.33
|
| Rate for Payer: Dean Health Medicaid |
$17.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.77
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.77
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.77
|
| Rate for Payer: Managed Health Services Medicaid |
$18.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.77
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$25.16
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.33
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$159.25
|
| Rate for Payer: Quartz Medicare Advantage |
$16.77
|
| Rate for Payer: The Alliance Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicaid |
$17.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.77
|
| Rate for Payer: United Healthcare PPO |
$183.75
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: Wellcare Medicare |
$16.77
|
| Rate for Payer: WMAP Medicaid |
$17.33
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
AFP Maternal / 5059
|
Professional
|
$245.00
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
977774
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Aetna Commercial |
$232.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Aetna Managed Medicare |
$16.77
|
| Rate for Payer: Anthem Medicare Advantage |
$16.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.77
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$232.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.77
|
| Rate for Payer: Health EOS Commercial |
$222.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.77
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: Preferred Network Access Commercial |
$232.75
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$139.65
|
| Rate for Payer: Quartz Medicare Advantage |
$16.77
|
| Rate for Payer: The Alliance Commercial |
$66.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.77
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$73.79
|
|
|
AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC
|
Facility
IP
|
$30,418.00
|
|
|
Service Code
|
MS-DRG 560
|
| Min. Negotiated Rate |
$10,941.87 |
| Max. Negotiated Rate |
$30,418.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,941.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,707.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,171.53
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,264.14
|
| Rate for Payer: Anthem Medicare Advantage |
$10,941.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,941.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,941.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,941.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,164.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,941.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22,075.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,941.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,941.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,941.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,941.87
|
| Rate for Payer: NAPHCARE Commercial |
$16,412.80
|
| Rate for Payer: Quartz Medicare Advantage |
$10,941.87
|
| Rate for Payer: The Alliance Commercial |
$30,418.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,941.87
|
| Rate for Payer: United Healthcare PPO |
$17,186.41
|
| Rate for Payer: Wellcare Medicare |
$10,941.87
|
|
