|
SHOE POST-OP FEMALE SMALL 4-6 DS1013-10
|
Facility
IP
|
$192.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963929
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$94.08 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.76
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$176.64
|
| Rate for Payer: Health EOS Commercial |
$170.88
|
| Rate for Payer: HFN Commercial |
$176.64
|
| Rate for Payer: Multiplan Commercial |
$153.60
|
| Rate for Payer: NAPHCARE Commercial |
$115.20
|
| Rate for Payer: Preferred Network Access Commercial |
$176.64
|
| Rate for Payer: Quartz Beloit One Network |
$94.08
|
| Rate for Payer: Quartz Commercial |
$115.20
|
| Rate for Payer: WEA Trust Commercial |
$105.60
|
| Rate for Payer: WPS Commercial |
$142.21
|
|
|
SHOE POST-OP MALE LRG 10.5-12 DS1014-14
|
Facility
OP
|
$192.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963924
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.12
|
| Rate for Payer: Aetna Managed Medicare |
$53.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.57
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.76
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$176.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.44
|
| Rate for Payer: Health EOS Commercial |
$170.88
|
| Rate for Payer: HFN Commercial |
$176.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$153.60
|
| Rate for Payer: NAPHCARE Commercial |
$115.20
|
| Rate for Payer: Preferred Network Access Commercial |
$176.64
|
| Rate for Payer: Quartz Beloit One Network |
$94.08
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: Quartz Medicare Advantage |
$115.20
|
| Rate for Payer: The Alliance Commercial |
$768.00
|
| Rate for Payer: WEA Trust Commercial |
$105.60
|
| Rate for Payer: WPS Commercial |
$142.21
|
|
|
SHOE POST-OP MALE LRG 10.5-12 DS1014-14
|
Facility
IP
|
$192.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963924
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$94.08 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.76
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$176.64
|
| Rate for Payer: Health EOS Commercial |
$170.88
|
| Rate for Payer: HFN Commercial |
$176.64
|
| Rate for Payer: Multiplan Commercial |
$153.60
|
| Rate for Payer: NAPHCARE Commercial |
$115.20
|
| Rate for Payer: Preferred Network Access Commercial |
$176.64
|
| Rate for Payer: Quartz Beloit One Network |
$94.08
|
| Rate for Payer: Quartz Commercial |
$115.20
|
| Rate for Payer: WEA Trust Commercial |
$105.60
|
| Rate for Payer: WPS Commercial |
$142.21
|
|
|
SHOE POST-OP MALE MED 8.5-10 DS1014-12
|
Facility
OP
|
$184.00
|
|
| Hospital Charge Code |
2963925
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
SHOE POST-OP MALE MED 8.5-10 DS1014-12
|
Facility
IP
|
$184.00
|
|
| Hospital Charge Code |
2963925
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
SHOE POST-OP MALE SMALL 6-8 DS1014-10
|
Facility
OP
|
$185.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963926
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$740.00 |
| Rate for Payer: Aetna Commercial |
$166.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.10
|
| Rate for Payer: Aetna Managed Medicare |
$51.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.57
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.05
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$170.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.53
|
| Rate for Payer: Health EOS Commercial |
$164.65
|
| Rate for Payer: HFN Commercial |
$170.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.75
|
| Rate for Payer: Multiplan Commercial |
$148.00
|
| Rate for Payer: NAPHCARE Commercial |
$111.00
|
| Rate for Payer: Preferred Network Access Commercial |
$170.20
|
| Rate for Payer: Quartz Beloit One Network |
$90.65
|
| Rate for Payer: Quartz Commercial |
$120.25
|
| Rate for Payer: Quartz Medicare Advantage |
$111.00
|
| Rate for Payer: The Alliance Commercial |
$740.00
|
| Rate for Payer: WEA Trust Commercial |
$101.75
|
| Rate for Payer: WPS Commercial |
$137.03
|
|
|
SHOE POST-OP MALE SMALL 6-8 DS1014-10
|
Facility
IP
|
$185.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963926
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$90.65 |
| Max. Negotiated Rate |
$170.20 |
| Rate for Payer: Aetna Commercial |
$166.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.05
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$170.20
|
| Rate for Payer: Health EOS Commercial |
$164.65
|
| Rate for Payer: HFN Commercial |
$170.20
|
| Rate for Payer: Multiplan Commercial |
$148.00
|
| Rate for Payer: NAPHCARE Commercial |
$111.00
|
| Rate for Payer: Preferred Network Access Commercial |
$170.20
|
| Rate for Payer: Quartz Beloit One Network |
$90.65
|
| Rate for Payer: Quartz Commercial |
$111.00
|
| Rate for Payer: WEA Trust Commercial |
$101.75
|
| Rate for Payer: WPS Commercial |
$137.03
|
|
|
SHOE POST-OP MALE XL 12.5-14 DS1014-16
|
Facility
IP
|
$184.00
|
|
| Hospital Charge Code |
2963923
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
SHOE POST-OP MALE XL 12.5-14 DS1014-16
|
Facility
OP
|
$184.00
|
|
| Hospital Charge Code |
2963923
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
SHOE SWEDISH AFO LEFT BLACK
|
Facility
OP
|
$525.00
|
|
| Hospital Charge Code |
2971357
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: Aetna Commercial |
$472.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$451.50
|
| Rate for Payer: Aetna Managed Medicare |
$147.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$341.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$262.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$252.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.25
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$483.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$293.79
|
| Rate for Payer: Health EOS Commercial |
$467.25
|
| Rate for Payer: HFN Commercial |
$483.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$393.75
|
| Rate for Payer: Multiplan Commercial |
$420.00
|
| Rate for Payer: NAPHCARE Commercial |
$315.00
|
| Rate for Payer: Preferred Network Access Commercial |
$483.00
|
| Rate for Payer: Quartz Beloit One Network |
$257.25
|
| Rate for Payer: Quartz Commercial |
$341.25
|
| Rate for Payer: Quartz Medicare Advantage |
$315.00
|
| Rate for Payer: The Alliance Commercial |
$2,100.00
|
| Rate for Payer: WEA Trust Commercial |
$288.75
|
| Rate for Payer: WPS Commercial |
$388.87
|
|
|
SHOE SWEDISH AFO LEFT BLACK
|
Facility
IP
|
$525.00
|
|
| Hospital Charge Code |
2971357
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$257.25 |
| Max. Negotiated Rate |
$483.00 |
| Rate for Payer: Aetna Commercial |
$472.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.25
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$483.00
|
| Rate for Payer: Health EOS Commercial |
$467.25
|
| Rate for Payer: HFN Commercial |
$483.00
|
| Rate for Payer: Multiplan Commercial |
$420.00
|
| Rate for Payer: NAPHCARE Commercial |
$315.00
|
| Rate for Payer: Preferred Network Access Commercial |
$483.00
|
| Rate for Payer: Quartz Beloit One Network |
$257.25
|
| Rate for Payer: Quartz Commercial |
$315.00
|
| Rate for Payer: WEA Trust Commercial |
$288.75
|
| Rate for Payer: WPS Commercial |
$388.87
|
|
|
Short Increment Sensitivity Index
|
Facility
OP
|
$148.00
|
|
| Hospital Charge Code |
1188817
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$592.00 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Aetna Managed Medicare |
$41.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.82
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.00
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$96.20
|
| Rate for Payer: Quartz Medicare Advantage |
$88.80
|
| Rate for Payer: The Alliance Commercial |
$592.00
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
Short Increment Sensitivity Index
|
Professional
|
$148.00
|
|
| Hospital Charge Code |
1188817
|
| Min. Negotiated Rate |
$65.12 |
| Max. Negotiated Rate |
$140.60 |
| Rate for Payer: Aetna Commercial |
$140.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$140.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.80
|
| Rate for Payer: Health EOS Commercial |
$134.68
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: Preferred Network Access Commercial |
$140.60
|
| Rate for Payer: Quartz Beloit One Network |
$65.12
|
| Rate for Payer: Quartz Commercial |
$84.36
|
| Rate for Payer: The Alliance Commercial |
$74.00
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
Short Increment Sensitivity Index
|
Facility
IP
|
$148.00
|
|
| Hospital Charge Code |
1188817
|
| Min. Negotiated Rate |
$72.52 |
| Max. Negotiated Rate |
$136.16 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$88.80
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
Short Increment Sensity. Index
|
Facility
OP
|
$148.00
|
|
| Hospital Charge Code |
3203500
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$592.00 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Aetna Managed Medicare |
$41.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.82
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.00
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$96.20
|
| Rate for Payer: Quartz Medicare Advantage |
$88.80
|
| Rate for Payer: The Alliance Commercial |
$592.00
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
Short Increment Sensity. Index
|
Facility
IP
|
$148.00
|
|
| Hospital Charge Code |
3203500
|
| Min. Negotiated Rate |
$72.52 |
| Max. Negotiated Rate |
$136.16 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$88.80
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
Short Increment Sensity. Index
|
Professional
|
$148.00
|
|
| Hospital Charge Code |
3203500
|
| Min. Negotiated Rate |
$65.12 |
| Max. Negotiated Rate |
$140.60 |
| Rate for Payer: The Alliance Commercial |
$74.00
|
| Rate for Payer: Aetna Commercial |
$140.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$140.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.80
|
| Rate for Payer: Health EOS Commercial |
$134.68
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: Preferred Network Access Commercial |
$140.60
|
| Rate for Payer: Quartz Beloit One Network |
$65.12
|
| Rate for Payer: Quartz Commercial |
$84.36
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
Shoulder Arthrogram XR Left
|
Facility
IP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
3072707
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$555.17 |
| Max. Negotiated Rate |
$1,042.36 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$679.80
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
Shoulder Arthrogram XR Left
|
Facility
OP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
3072707
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$2,397.36 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Aetna Managed Medicare |
$317.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$736.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$543.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$849.75
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$736.45
|
| Rate for Payer: Quartz Medicare Advantage |
$679.80
|
| Rate for Payer: The Alliance Commercial |
$2,397.36
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
Shoulder Arthrogram XR Left
|
Professional
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
3072707
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$112.51 |
| Max. Negotiated Rate |
$1,076.35 |
| Rate for Payer: Aetna Commercial |
$1,076.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Aetna Managed Medicare |
$112.51
|
| Rate for Payer: Anthem Medicare Advantage |
$112.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$112.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$112.51
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,076.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$566.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.51
|
| Rate for Payer: Health EOS Commercial |
$1,031.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$395.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$395.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$112.51
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,076.35
|
| Rate for Payer: Quartz Beloit One Network |
$498.52
|
| Rate for Payer: Quartz Commercial |
$645.81
|
| Rate for Payer: Quartz Medicare Advantage |
$112.51
|
| Rate for Payer: The Alliance Commercial |
$427.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$112.51
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$562.55
|
|
|
Shoulder Arthrogram XR Right
|
Professional
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
3072708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$112.51 |
| Max. Negotiated Rate |
$1,076.35 |
| Rate for Payer: Aetna Commercial |
$1,076.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Aetna Managed Medicare |
$112.51
|
| Rate for Payer: Anthem Medicare Advantage |
$112.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$112.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$112.51
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,076.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$566.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.51
|
| Rate for Payer: Health EOS Commercial |
$1,031.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$395.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$395.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$112.51
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,076.35
|
| Rate for Payer: Quartz Beloit One Network |
$498.52
|
| Rate for Payer: Quartz Commercial |
$645.81
|
| Rate for Payer: Quartz Medicare Advantage |
$112.51
|
| Rate for Payer: The Alliance Commercial |
$427.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$112.51
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$562.55
|
|
|
Shoulder Arthrogram XR Right
|
Facility
IP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
3072708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$555.17 |
| Max. Negotiated Rate |
$1,042.36 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$679.80
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
Shoulder Arthrogram XR Right
|
Facility
OP
|
$1,133.00
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
3072708
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$2,397.36 |
| Rate for Payer: Aetna Commercial |
$1,019.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$974.38
|
| Rate for Payer: Aetna Managed Medicare |
$317.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$736.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$566.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$543.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$600.49
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cash Price |
$339.90
|
| Rate for Payer: Cigna Commercial |
$1,042.36
|
| Rate for Payer: Health EOS Commercial |
$1,008.37
|
| Rate for Payer: HFN Commercial |
$1,042.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$849.75
|
| Rate for Payer: Multiplan Commercial |
$906.40
|
| Rate for Payer: NAPHCARE Commercial |
$679.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,042.36
|
| Rate for Payer: Quartz Beloit One Network |
$555.17
|
| Rate for Payer: Quartz Commercial |
$736.45
|
| Rate for Payer: Quartz Medicare Advantage |
$679.80
|
| Rate for Payer: The Alliance Commercial |
$2,397.36
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$623.15
|
| Rate for Payer: WPS Commercial |
$839.21
|
|
|
SHOULDER ARTHROPLASTY/HEMIARTHROPLASTY
|
Facility
OP
|
$13,037.00
|
|
| Hospital Charge Code |
2960444
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,650.36 |
| Max. Negotiated Rate |
$52,148.00 |
| Rate for Payer: Aetna Commercial |
$11,733.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,211.82
|
| Rate for Payer: Aetna Managed Medicare |
$3,650.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,474.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,518.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,257.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,909.61
|
| Rate for Payer: Cash Price |
$3,911.10
|
| Rate for Payer: Cigna Commercial |
$11,994.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,295.51
|
| Rate for Payer: Health EOS Commercial |
$11,602.93
|
| Rate for Payer: HFN Commercial |
$11,994.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,777.75
|
| Rate for Payer: Multiplan Commercial |
$10,429.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,822.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,994.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,388.13
|
| Rate for Payer: Quartz Commercial |
$8,474.05
|
| Rate for Payer: Quartz Medicare Advantage |
$7,822.20
|
| Rate for Payer: The Alliance Commercial |
$52,148.00
|
| Rate for Payer: WEA Trust Commercial |
$7,170.35
|
| Rate for Payer: WPS Commercial |
$9,656.51
|
|
|
SHOULDER ARTHROPLASTY/HEMIARTHROPLASTY
|
Facility
IP
|
$13,037.00
|
|
| Hospital Charge Code |
2960444
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,388.13 |
| Max. Negotiated Rate |
$11,994.04 |
| Rate for Payer: Aetna Commercial |
$11,733.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,909.61
|
| Rate for Payer: Cash Price |
$3,911.10
|
| Rate for Payer: Cigna Commercial |
$11,994.04
|
| Rate for Payer: Health EOS Commercial |
$11,602.93
|
| Rate for Payer: HFN Commercial |
$11,994.04
|
| Rate for Payer: Multiplan Commercial |
$10,429.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,822.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,994.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,388.13
|
| Rate for Payer: Quartz Commercial |
$7,822.20
|
| Rate for Payer: WEA Trust Commercial |
$7,170.35
|
| Rate for Payer: WPS Commercial |
$9,656.51
|
|
