|
Affinity per sq cm Q4159
|
Facility
|
IP
|
$1,135.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5362662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$578.40 |
| Max. Negotiated Rate |
$1,085.97 |
| Rate for Payer: Aetna Commercial |
$1,062.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.61
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,085.97
|
| Rate for Payer: Health EOS Commercial |
$1,050.56
|
| Rate for Payer: HFN Commercial |
$1,085.97
|
| Rate for Payer: Multiplan Commercial |
$944.32
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.97
|
| Rate for Payer: Quartz Beloit One Network |
$578.40
|
| Rate for Payer: Quartz Commercial |
$708.24
|
| Rate for Payer: WEA Trust Commercial |
$649.22
|
| Rate for Payer: WPS Commercial |
$874.29
|
|
|
Affinity per sq cm Q4159
|
Facility
|
OP
|
$1,135.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5362662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$1,085.97 |
| Rate for Payer: Aetna Commercial |
$1,062.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.14
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$767.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$590.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$566.59
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,085.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$425.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$1,050.56
|
| Rate for Payer: HFN Commercial |
$1,085.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$944.32
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.97
|
| Rate for Payer: Quartz Beloit One Network |
$578.40
|
| Rate for Payer: Quartz Commercial |
$767.26
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$649.22
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$804.90
|
|
|
Affinity per sq cm Q4159
|
Professional
|
Both
|
$1,135.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5362662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.79 |
| Max. Negotiated Rate |
$2,366.01 |
| Rate for Payer: Aetna Commercial |
$1,121.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.14
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,121.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$590.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.96
|
| Rate for Payer: Health EOS Commercial |
$1,074.16
|
| Rate for Payer: HFN Commercial |
$1,121.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,366.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,366.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$944.32
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,121.38
|
| Rate for Payer: Quartz Beloit One Network |
$519.38
|
| Rate for Payer: Quartz Commercial |
$672.83
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$649.22
|
| Rate for Payer: WPS Commercial |
$804.90
|
|
|
Afo ankle gauntlet L1902
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
3133612
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$128.21 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$83.62
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
Afo ankle gauntlet L1902
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
3133612
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$39.02 |
| Max. Negotiated Rate |
$381.60 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Aetna Managed Medicare |
$39.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.99
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.52
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: NAPHCARE Commercial |
$83.62
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$90.58
|
| Rate for Payer: Quartz Medicare Advantage |
$83.62
|
| Rate for Payer: The Alliance Commercial |
$381.60
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
Afo ankle gauntlet L1902
|
Professional
|
Both
|
$134.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
3133612
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$61.32 |
| Max. Negotiated Rate |
$275.08 |
| Rate for Payer: Aetna Commercial |
$132.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Aetna Managed Medicare |
$95.40
|
| Rate for Payer: Anthem Medicare Advantage |
$95.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$95.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$95.40
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$132.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.40
|
| Rate for Payer: Health EOS Commercial |
$126.82
|
| Rate for Payer: HFN Commercial |
$132.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$275.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$95.40
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: NAPHCARE Commercial |
$143.10
|
| Rate for Payer: Preferred Network Access Commercial |
$132.39
|
| Rate for Payer: Quartz Beloit One Network |
$61.32
|
| Rate for Payer: Quartz Commercial |
$79.44
|
| Rate for Payer: Quartz Medicare Advantage |
$95.40
|
| Rate for Payer: The Alliance Commercial |
$262.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$95.40
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$166.95
|
|
|
Afo molded to patient plasti L1940
|
Facility
|
IP
|
$1,244.00
|
|
|
Service Code
|
HCPCS L1940
|
| Hospital Charge Code |
4075824
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$633.94 |
| Max. Negotiated Rate |
$1,190.26 |
| Rate for Payer: Aetna Commercial |
$1,164.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,112.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$685.69
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$1,190.26
|
| Rate for Payer: Health EOS Commercial |
$1,151.45
|
| Rate for Payer: HFN Commercial |
$1,190.26
|
| Rate for Payer: Multiplan Commercial |
$1,035.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,190.26
|
| Rate for Payer: Quartz Beloit One Network |
$633.94
|
| Rate for Payer: Quartz Commercial |
$776.26
|
| Rate for Payer: WEA Trust Commercial |
$711.57
|
| Rate for Payer: WPS Commercial |
$958.25
|
|
|
Afo molded to patient plasti L1940
|
Facility
|
OP
|
$1,244.00
|
|
|
Service Code
|
HCPCS L1940
|
| Hospital Charge Code |
4075824
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$297.19 |
| Max. Negotiated Rate |
$2,489.64 |
| Rate for Payer: Aetna Commercial |
$1,164.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,112.63
|
| Rate for Payer: Aetna Managed Medicare |
$362.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$297.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$297.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$685.69
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$1,190.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$724.01
|
| Rate for Payer: Health EOS Commercial |
$1,151.45
|
| Rate for Payer: HFN Commercial |
$1,190.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$970.32
|
| Rate for Payer: Multiplan Commercial |
$1,035.01
|
| Rate for Payer: NAPHCARE Commercial |
$776.26
|
| Rate for Payer: Preferred Network Access Commercial |
$1,190.26
|
| Rate for Payer: Quartz Beloit One Network |
$633.94
|
| Rate for Payer: Quartz Commercial |
$840.94
|
| Rate for Payer: Quartz Medicare Advantage |
$776.26
|
| Rate for Payer: The Alliance Commercial |
$2,489.64
|
| Rate for Payer: WEA Trust Commercial |
$711.57
|
| Rate for Payer: WPS Commercial |
$958.25
|
|
|
Afo molded to patient plasti L1940
|
Professional
|
Both
|
$1,244.00
|
|
|
Service Code
|
HCPCS L1940
|
| Hospital Charge Code |
4075824
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$569.25 |
| Max. Negotiated Rate |
$1,794.63 |
| Rate for Payer: Aetna Commercial |
$1,229.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,112.63
|
| Rate for Payer: Aetna Managed Medicare |
$622.41
|
| Rate for Payer: Anthem Medicare Advantage |
$622.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$622.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$622.41
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$1,229.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$646.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$622.41
|
| Rate for Payer: Health EOS Commercial |
$1,177.32
|
| Rate for Payer: HFN Commercial |
$1,229.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,794.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,794.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$622.41
|
| Rate for Payer: Multiplan Commercial |
$1,035.01
|
| Rate for Payer: NAPHCARE Commercial |
$933.61
|
| Rate for Payer: Preferred Network Access Commercial |
$1,229.07
|
| Rate for Payer: Quartz Beloit One Network |
$569.25
|
| Rate for Payer: Quartz Commercial |
$737.44
|
| Rate for Payer: Quartz Medicare Advantage |
$622.41
|
| Rate for Payer: The Alliance Commercial |
$1,711.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$622.41
|
| Rate for Payer: WEA Trust Commercial |
$711.57
|
| Rate for Payer: WPS Commercial |
$1,089.22
|
|
|
Afo multiligamentus ankle su L1906
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS L1906
|
| Hospital Charge Code |
3898157
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$29.95
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Afo multiligamentus ankle su L1906
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS L1906
|
| Hospital Charge Code |
3898157
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$574.91 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.94
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.44
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$32.45
|
| Rate for Payer: Quartz Medicare Advantage |
$29.95
|
| Rate for Payer: The Alliance Commercial |
$574.91
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Afo multiligamentus ankle su L1906
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
HCPCS L1906
|
| Hospital Charge Code |
3898157
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$21.96 |
| Max. Negotiated Rate |
$414.41 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$143.73
|
| Rate for Payer: Anthem Medicare Advantage |
$143.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$143.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$143.73
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$47.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.73
|
| Rate for Payer: Health EOS Commercial |
$45.43
|
| Rate for Payer: HFN Commercial |
$47.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$414.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$143.73
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$215.59
|
| Rate for Payer: Preferred Network Access Commercial |
$47.42
|
| Rate for Payer: Quartz Beloit One Network |
$21.96
|
| Rate for Payer: Quartz Commercial |
$28.45
|
| Rate for Payer: Quartz Medicare Advantage |
$143.73
|
| Rate for Payer: The Alliance Commercial |
$395.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$143.73
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$251.52
|
|
|
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 |
$383.82 |
| Max. Negotiated Rate |
$3,538.54 |
| Rate for Payer: Aetna Commercial |
$1,614.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,542.84
|
| Rate for Payer: Aetna Managed Medicare |
$502.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$383.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$383.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$383.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$950.82
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$1,650.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,003.95
|
| Rate for Payer: Health EOS Commercial |
$1,596.66
|
| Rate for Payer: HFN Commercial |
$1,650.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,345.50
|
| Rate for Payer: Multiplan Commercial |
$1,435.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,076.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,650.48
|
| Rate for Payer: Quartz Beloit One Network |
$879.06
|
| Rate for Payer: Quartz Commercial |
$1,166.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,076.40
|
| Rate for Payer: The Alliance Commercial |
$3,538.54
|
| Rate for Payer: WEA Trust Commercial |
$986.70
|
| Rate for Payer: WPS Commercial |
$1,328.77
|
|
|
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 |
$879.06 |
| Max. Negotiated Rate |
$1,650.48 |
| Rate for Payer: Aetna Commercial |
$1,614.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,542.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$950.82
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$1,650.48
|
| Rate for Payer: Health EOS Commercial |
$1,596.66
|
| Rate for Payer: HFN Commercial |
$1,650.48
|
| Rate for Payer: Multiplan Commercial |
$1,435.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,650.48
|
| Rate for Payer: Quartz Beloit One Network |
$879.06
|
| Rate for Payer: Quartz Commercial |
$1,076.40
|
| Rate for Payer: WEA Trust Commercial |
$986.70
|
| Rate for Payer: WPS Commercial |
$1,328.77
|
|
|
Afo plastic molded w/ankle j L1970
|
Professional
|
Both
|
$1,725.00
|
|
|
Service Code
|
HCPCS L1970
|
| Hospital Charge Code |
4075995
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$789.36 |
| Max. Negotiated Rate |
$2,550.67 |
| Rate for Payer: Aetna Commercial |
$1,704.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,542.84
|
| Rate for Payer: Aetna Managed Medicare |
$884.63
|
| Rate for Payer: Anthem Medicare Advantage |
$884.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$884.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$884.63
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$1,704.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$897.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$884.63
|
| Rate for Payer: Health EOS Commercial |
$1,632.54
|
| Rate for Payer: HFN Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,550.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,550.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$884.63
|
| Rate for Payer: Multiplan Commercial |
$1,435.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,326.95
|
| Rate for Payer: Preferred Network Access Commercial |
$1,704.30
|
| Rate for Payer: Quartz Beloit One Network |
$789.36
|
| Rate for Payer: Quartz Commercial |
$1,022.58
|
| Rate for Payer: Quartz Medicare Advantage |
$884.63
|
| Rate for Payer: The Alliance Commercial |
$2,432.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$884.63
|
| Rate for Payer: WEA Trust Commercial |
$986.70
|
| Rate for Payer: WPS Commercial |
$1,548.11
|
|
|
AFO PRESSURE RELIEF
|
Facility
|
OP
|
$3,049.00
|
|
| Hospital Charge Code |
2974156
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$887.87 |
| Max. Negotiated Rate |
$2,917.28 |
| Rate for Payer: Aetna Commercial |
$2,853.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.03
|
| Rate for Payer: Aetna Managed Medicare |
$887.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,061.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,585.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,522.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,680.61
|
| Rate for Payer: Cash Price |
$914.70
|
| Rate for Payer: Cigna Commercial |
$2,917.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,774.52
|
| Rate for Payer: Health EOS Commercial |
$2,822.15
|
| Rate for Payer: HFN Commercial |
$2,917.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,378.22
|
| Rate for Payer: Multiplan Commercial |
$2,536.77
|
| Rate for Payer: NAPHCARE Commercial |
$1,902.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,917.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,553.77
|
| Rate for Payer: Quartz Commercial |
$2,061.12
|
| Rate for Payer: Quartz Medicare Advantage |
$1,902.58
|
| Rate for Payer: The Alliance Commercial |
$1,585.48
|
| Rate for Payer: WEA Trust Commercial |
$1,744.03
|
| Rate for Payer: WPS Commercial |
$2,348.64
|
|
|
AFO PRESSURE RELIEF
|
Facility
|
IP
|
$3,049.00
|
|
| Hospital Charge Code |
2974156
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,553.77 |
| Max. Negotiated Rate |
$2,917.28 |
| Rate for Payer: Aetna Commercial |
$2,853.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,680.61
|
| Rate for Payer: Cash Price |
$914.70
|
| Rate for Payer: Cigna Commercial |
$2,917.28
|
| Rate for Payer: Health EOS Commercial |
$2,822.15
|
| Rate for Payer: HFN Commercial |
$2,917.28
|
| Rate for Payer: Multiplan Commercial |
$2,536.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,917.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,553.77
|
| Rate for Payer: Quartz Commercial |
$1,902.58
|
| Rate for Payer: WEA Trust Commercial |
$1,744.03
|
| Rate for Payer: WPS Commercial |
$2,348.64
|
|
|
AFO, RIGID ANT TIBIAL SECTION, TOTAL CARBON FIBER/EQUAL MTRIAL, PREFAB, INCL FITTING & ADJS- L1932
|
Professional
|
Both
|
$1,092.00
|
|
|
Service Code
|
HCPCS L1932
|
| Hospital Charge Code |
6195786
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$499.70 |
| Max. Negotiated Rate |
$3,288.48 |
| Rate for Payer: Aetna Commercial |
$1,078.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,140.51
|
| Rate for Payer: Anthem Medicare Advantage |
$1,140.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,140.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,140.51
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,078.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$567.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,140.51
|
| Rate for Payer: Health EOS Commercial |
$1,033.47
|
| Rate for Payer: HFN Commercial |
$1,078.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,288.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,288.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,140.51
|
| Rate for Payer: Multiplan Commercial |
$908.54
|
| Rate for Payer: NAPHCARE Commercial |
$1,710.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,078.90
|
| Rate for Payer: Quartz Beloit One Network |
$499.70
|
| Rate for Payer: Quartz Commercial |
$647.34
|
| Rate for Payer: Quartz Medicare Advantage |
$1,140.51
|
| Rate for Payer: The Alliance Commercial |
$3,136.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,140.51
|
| Rate for Payer: WEA Trust Commercial |
$624.62
|
| Rate for Payer: WPS Commercial |
$1,995.88
|
|
|
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 |
$556.48 |
| Max. Negotiated Rate |
$1,044.83 |
| Rate for Payer: Aetna Commercial |
$1,022.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$601.91
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,044.83
|
| Rate for Payer: Health EOS Commercial |
$1,010.76
|
| Rate for Payer: HFN Commercial |
$1,044.83
|
| Rate for Payer: Multiplan Commercial |
$908.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,044.83
|
| Rate for Payer: Quartz Beloit One Network |
$556.48
|
| Rate for Payer: Quartz Commercial |
$681.41
|
| Rate for Payer: WEA Trust Commercial |
$624.62
|
| Rate for Payer: WPS Commercial |
$841.17
|
|
|
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 |
$317.99 |
| Max. Negotiated Rate |
$4,562.02 |
| Rate for Payer: Aetna Commercial |
$1,022.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.68
|
| Rate for Payer: Aetna Managed Medicare |
$317.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$420.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$420.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$420.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$601.91
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna Commercial |
$1,044.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$635.54
|
| Rate for Payer: Health EOS Commercial |
$1,010.76
|
| Rate for Payer: HFN Commercial |
$1,044.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$851.76
|
| Rate for Payer: Multiplan Commercial |
$908.54
|
| Rate for Payer: NAPHCARE Commercial |
$681.41
|
| Rate for Payer: Preferred Network Access Commercial |
$1,044.83
|
| Rate for Payer: Quartz Beloit One Network |
$556.48
|
| Rate for Payer: Quartz Commercial |
$738.19
|
| Rate for Payer: Quartz Medicare Advantage |
$681.41
|
| Rate for Payer: The Alliance Commercial |
$4,562.02
|
| Rate for Payer: WEA Trust Commercial |
$624.62
|
| Rate for Payer: WPS Commercial |
$841.17
|
|
|
Afo sing bar clasp attach sh L1910
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS L1910
|
| Hospital Charge Code |
4548690
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$37.52 |
| Max. Negotiated Rate |
$1,033.48 |
| Rate for Payer: Aetna Commercial |
$81.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$358.44
|
| Rate for Payer: Anthem Medicare Advantage |
$358.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$358.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$358.44
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$81.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$358.44
|
| Rate for Payer: Health EOS Commercial |
$77.60
|
| Rate for Payer: HFN Commercial |
$81.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,033.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,033.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$358.44
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$537.65
|
| Rate for Payer: Preferred Network Access Commercial |
$81.02
|
| Rate for Payer: Quartz Beloit One Network |
$37.52
|
| Rate for Payer: Quartz Commercial |
$48.61
|
| Rate for Payer: Quartz Medicare Advantage |
$358.44
|
| Rate for Payer: The Alliance Commercial |
$985.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$358.44
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$627.26
|
|
|
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 |
$23.88 |
| Max. Negotiated Rate |
$1,433.74 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$175.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$175.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$175.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.72
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$51.17
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$55.43
|
| Rate for Payer: Quartz Medicare Advantage |
$51.17
|
| Rate for Payer: The Alliance Commercial |
$1,433.74
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
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 |
$41.79 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$51.17
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
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 |
$240.17 |
| Max. Negotiated Rate |
$2,064.23 |
| Rate for Payer: Aetna Commercial |
$911.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$871.15
|
| Rate for Payer: Aetna Managed Medicare |
$283.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$240.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$536.87
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$931.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$566.87
|
| Rate for Payer: Health EOS Commercial |
$901.53
|
| Rate for Payer: HFN Commercial |
$931.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$759.72
|
| Rate for Payer: Multiplan Commercial |
$810.37
|
| Rate for Payer: NAPHCARE Commercial |
$607.78
|
| Rate for Payer: Preferred Network Access Commercial |
$931.92
|
| Rate for Payer: Quartz Beloit One Network |
$496.35
|
| Rate for Payer: Quartz Commercial |
$658.42
|
| Rate for Payer: Quartz Medicare Advantage |
$607.78
|
| Rate for Payer: The Alliance Commercial |
$2,064.23
|
| Rate for Payer: WEA Trust Commercial |
$557.13
|
| Rate for Payer: WPS Commercial |
$750.27
|
|
|
Afo sing solid stirrup calf L1980
|
Professional
|
Both
|
$974.00
|
|
|
Service Code
|
HCPCS L1980
|
| Hospital Charge Code |
4526616
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$445.70 |
| Max. Negotiated Rate |
$1,487.97 |
| Rate for Payer: Aetna Commercial |
$962.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$871.15
|
| Rate for Payer: Aetna Managed Medicare |
$516.06
|
| Rate for Payer: Anthem Medicare Advantage |
$516.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$516.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$516.06
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$962.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$506.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$516.06
|
| Rate for Payer: Health EOS Commercial |
$921.79
|
| Rate for Payer: HFN Commercial |
$962.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,487.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,487.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$516.06
|
| Rate for Payer: Multiplan Commercial |
$810.37
|
| Rate for Payer: NAPHCARE Commercial |
$774.09
|
| Rate for Payer: Preferred Network Access Commercial |
$962.31
|
| Rate for Payer: Quartz Beloit One Network |
$445.70
|
| Rate for Payer: Quartz Commercial |
$577.39
|
| Rate for Payer: Quartz Medicare Advantage |
$516.06
|
| Rate for Payer: The Alliance Commercial |
$1,419.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$516.06
|
| Rate for Payer: WEA Trust Commercial |
$557.13
|
| Rate for Payer: WPS Commercial |
$903.10
|
|
