|
TOE CREST MEDIUM LEFT 31375
|
Facility
|
IP
|
$156.00
|
|
| Hospital Charge Code |
2971102
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$97.34
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
TOE CREST MEDIUM LEFT 31375
|
Facility
|
OP
|
$156.00
|
|
| Hospital Charge Code |
2971102
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Aetna Managed Medicare |
$45.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.79
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.68
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: NAPHCARE Commercial |
$97.34
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$105.46
|
| Rate for Payer: Quartz Medicare Advantage |
$97.34
|
| Rate for Payer: The Alliance Commercial |
$81.12
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
TOE CREST MEDIUM RIGHT 31372
|
Facility
|
IP
|
$156.00
|
|
| Hospital Charge Code |
2971101
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$97.34
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
TOE CREST MEDIUM RIGHT 31372
|
Facility
|
OP
|
$156.00
|
|
| Hospital Charge Code |
2971101
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Aetna Managed Medicare |
$45.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.79
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.68
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: NAPHCARE Commercial |
$97.34
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$105.46
|
| Rate for Payer: Quartz Medicare Advantage |
$97.34
|
| Rate for Payer: The Alliance Commercial |
$81.12
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
TOE CREST MED LEFT 6505-9
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2970996
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
TOE CREST MED LEFT 6505-9
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2970996
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
TOE CREST MED RT 6505-8
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2970995
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
TOE CREST MED RT 6505-8
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2970995
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
Toe Filler L5000
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
HCPCS L5000
|
| Hospital Charge Code |
5605758
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$2,935.75 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Aetna Managed Medicare |
$55.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$425.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$425.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$425.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.00
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.42
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: NAPHCARE Commercial |
$117.94
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$127.76
|
| Rate for Payer: Quartz Medicare Advantage |
$117.94
|
| Rate for Payer: The Alliance Commercial |
$2,935.75
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
Toe Filler L5000
|
Professional
|
Both
|
$189.00
|
|
|
Service Code
|
HCPCS L5000
|
| Hospital Charge Code |
5605758
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$86.49 |
| Max. Negotiated Rate |
$2,116.15 |
| Rate for Payer: Aetna Commercial |
$186.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Aetna Managed Medicare |
$733.94
|
| Rate for Payer: Anthem Medicare Advantage |
$733.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$733.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$733.94
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$186.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$733.94
|
| Rate for Payer: Health EOS Commercial |
$178.87
|
| Rate for Payer: HFN Commercial |
$186.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,116.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,116.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$733.94
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: NAPHCARE Commercial |
$1,100.91
|
| Rate for Payer: Preferred Network Access Commercial |
$186.73
|
| Rate for Payer: Quartz Beloit One Network |
$86.49
|
| Rate for Payer: Quartz Commercial |
$112.04
|
| Rate for Payer: Quartz Medicare Advantage |
$733.94
|
| Rate for Payer: The Alliance Commercial |
$2,018.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$733.94
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$1,284.39
|
|
|
Toe Filler L5000
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
HCPCS L5000
|
| Hospital Charge Code |
5605758
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$96.31 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$117.94
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
TOE OSTEOTOMY/ARTHRODESIS
|
Facility
|
IP
|
$4,912.00
|
|
| Hospital Charge Code |
2960297
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,503.16 |
| Max. Negotiated Rate |
$4,699.80 |
| Rate for Payer: Aetna Commercial |
$4,597.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,393.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,707.49
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,699.80
|
| Rate for Payer: Health EOS Commercial |
$4,546.55
|
| Rate for Payer: HFN Commercial |
$4,699.80
|
| Rate for Payer: Multiplan Commercial |
$4,086.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,699.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,503.16
|
| Rate for Payer: Quartz Commercial |
$3,065.09
|
| Rate for Payer: WEA Trust Commercial |
$2,809.66
|
| Rate for Payer: WPS Commercial |
$3,783.71
|
|
|
TOE OSTEOTOMY/ARTHRODESIS
|
Facility
|
OP
|
$4,912.00
|
|
| Hospital Charge Code |
2960297
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,430.37 |
| Max. Negotiated Rate |
$4,699.80 |
| Rate for Payer: Aetna Commercial |
$4,597.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,393.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,430.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,320.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,554.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,452.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,707.49
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,699.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,858.78
|
| Rate for Payer: Health EOS Commercial |
$4,546.55
|
| Rate for Payer: HFN Commercial |
$4,699.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,831.36
|
| Rate for Payer: Multiplan Commercial |
$4,086.78
|
| Rate for Payer: NAPHCARE Commercial |
$3,065.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,699.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,503.16
|
| Rate for Payer: Quartz Commercial |
$3,320.51
|
| Rate for Payer: Quartz Medicare Advantage |
$3,065.09
|
| Rate for Payer: The Alliance Commercial |
$2,554.24
|
| Rate for Payer: WEA Trust Commercial |
$2,809.66
|
| Rate for Payer: WPS Commercial |
$3,783.71
|
|
|
TOE SEPARATOR POLYFOAM 3 LAYER SMALL 8130-S
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
2969830
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Aetna Commercial |
$21.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.57
|
| Rate for Payer: Aetna Managed Medicare |
$6.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.68
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$22.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.39
|
| Rate for Payer: Health EOS Commercial |
$21.29
|
| Rate for Payer: HFN Commercial |
$22.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.94
|
| Rate for Payer: Multiplan Commercial |
$19.14
|
| Rate for Payer: NAPHCARE Commercial |
$14.35
|
| Rate for Payer: Preferred Network Access Commercial |
$22.01
|
| Rate for Payer: Quartz Beloit One Network |
$11.72
|
| Rate for Payer: Quartz Commercial |
$15.55
|
| Rate for Payer: Quartz Medicare Advantage |
$14.35
|
| Rate for Payer: The Alliance Commercial |
$11.96
|
| Rate for Payer: WEA Trust Commercial |
$13.16
|
| Rate for Payer: WPS Commercial |
$17.72
|
|
|
TOE SEPARATOR POLYFOAM 3 LAYER SMALL 8130-S
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
2969830
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$11.72 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Aetna Commercial |
$21.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.68
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$22.01
|
| Rate for Payer: Health EOS Commercial |
$21.29
|
| Rate for Payer: HFN Commercial |
$22.01
|
| Rate for Payer: Multiplan Commercial |
$19.14
|
| Rate for Payer: Preferred Network Access Commercial |
$22.01
|
| Rate for Payer: Quartz Beloit One Network |
$11.72
|
| Rate for Payer: Quartz Commercial |
$14.35
|
| Rate for Payer: WEA Trust Commercial |
$13.16
|
| Rate for Payer: WPS Commercial |
$17.72
|
|
|
TOE SPLINT #550692
|
Facility
|
OP
|
$224.00
|
|
| Hospital Charge Code |
2970711
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$214.32 |
| Rate for Payer: Aetna Commercial |
$209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Aetna Managed Medicare |
$65.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$151.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$116.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.47
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$214.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.37
|
| Rate for Payer: Health EOS Commercial |
$207.33
|
| Rate for Payer: HFN Commercial |
$214.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.72
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: NAPHCARE Commercial |
$139.78
|
| Rate for Payer: Preferred Network Access Commercial |
$214.32
|
| Rate for Payer: Quartz Beloit One Network |
$114.15
|
| Rate for Payer: Quartz Commercial |
$151.42
|
| Rate for Payer: Quartz Medicare Advantage |
$139.78
|
| Rate for Payer: The Alliance Commercial |
$116.48
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: WPS Commercial |
$172.55
|
|
|
TOE SPLINT #550692
|
Facility
|
IP
|
$224.00
|
|
| Hospital Charge Code |
2970711
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$114.15 |
| Max. Negotiated Rate |
$214.32 |
| Rate for Payer: Aetna Commercial |
$209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.47
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$214.32
|
| Rate for Payer: Health EOS Commercial |
$207.33
|
| Rate for Payer: HFN Commercial |
$214.32
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: Preferred Network Access Commercial |
$214.32
|
| Rate for Payer: Quartz Beloit One Network |
$114.15
|
| Rate for Payer: Quartz Commercial |
$139.78
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: WPS Commercial |
$172.55
|
|
|
TOE, TENDON & NERVE REPAIR
|
Facility
|
OP
|
$1,242.00
|
|
| Hospital Charge Code |
2960425
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$361.67 |
| Max. Negotiated Rate |
$1,188.35 |
| Rate for Payer: Aetna Commercial |
$1,162.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,110.84
|
| Rate for Payer: Aetna Managed Medicare |
$361.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$839.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$645.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$620.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$684.59
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,188.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$722.84
|
| Rate for Payer: Health EOS Commercial |
$1,149.60
|
| Rate for Payer: HFN Commercial |
$1,188.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$968.76
|
| Rate for Payer: Multiplan Commercial |
$1,033.34
|
| Rate for Payer: NAPHCARE Commercial |
$775.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,188.35
|
| Rate for Payer: Quartz Beloit One Network |
$632.92
|
| Rate for Payer: Quartz Commercial |
$839.59
|
| Rate for Payer: Quartz Medicare Advantage |
$775.01
|
| Rate for Payer: The Alliance Commercial |
$645.84
|
| Rate for Payer: WEA Trust Commercial |
$710.42
|
| Rate for Payer: WPS Commercial |
$956.71
|
|
|
TOE, TENDON & NERVE REPAIR
|
Facility
|
IP
|
$1,242.00
|
|
| Hospital Charge Code |
2960425
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$632.92 |
| Max. Negotiated Rate |
$1,188.35 |
| Rate for Payer: Aetna Commercial |
$1,162.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,110.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$684.59
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,188.35
|
| Rate for Payer: Health EOS Commercial |
$1,149.60
|
| Rate for Payer: HFN Commercial |
$1,188.35
|
| Rate for Payer: Multiplan Commercial |
$1,033.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,188.35
|
| Rate for Payer: Quartz Beloit One Network |
$632.92
|
| Rate for Payer: Quartz Commercial |
$775.01
|
| Rate for Payer: WEA Trust Commercial |
$710.42
|
| Rate for Payer: WPS Commercial |
$956.71
|
|
|
TOGA FLYTE X-LARGE 408-830
|
Facility
|
IP
|
$1,370.00
|
|
| Hospital Charge Code |
4089815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$698.15 |
| Max. Negotiated Rate |
$1,310.82 |
| Rate for Payer: Aetna Commercial |
$1,282.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,225.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$755.14
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$1,310.82
|
| Rate for Payer: Health EOS Commercial |
$1,268.07
|
| Rate for Payer: HFN Commercial |
$1,310.82
|
| Rate for Payer: Multiplan Commercial |
$1,139.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,310.82
|
| Rate for Payer: Quartz Beloit One Network |
$698.15
|
| Rate for Payer: Quartz Commercial |
$854.88
|
| Rate for Payer: WEA Trust Commercial |
$783.64
|
| Rate for Payer: WPS Commercial |
$1,055.31
|
|
|
TOGA FLYTE X-LARGE 408-830
|
Facility
|
OP
|
$1,370.00
|
|
| Hospital Charge Code |
4089815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$398.94 |
| Max. Negotiated Rate |
$1,310.82 |
| Rate for Payer: Aetna Commercial |
$1,282.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,225.33
|
| Rate for Payer: Aetna Managed Medicare |
$398.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$926.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$712.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$683.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$755.14
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$1,310.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$797.34
|
| Rate for Payer: Health EOS Commercial |
$1,268.07
|
| Rate for Payer: HFN Commercial |
$1,310.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,068.60
|
| Rate for Payer: Multiplan Commercial |
$1,139.84
|
| Rate for Payer: NAPHCARE Commercial |
$854.88
|
| Rate for Payer: Preferred Network Access Commercial |
$1,310.82
|
| Rate for Payer: Quartz Beloit One Network |
$698.15
|
| Rate for Payer: Quartz Commercial |
$926.12
|
| Rate for Payer: Quartz Medicare Advantage |
$854.88
|
| Rate for Payer: The Alliance Commercial |
$712.40
|
| Rate for Payer: WEA Trust Commercial |
$783.64
|
| Rate for Payer: WPS Commercial |
$1,055.31
|
|
|
TOGA FLYTE XXL 0408-840-000
|
Facility
|
OP
|
$1,117.00
|
|
| Hospital Charge Code |
2966090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$325.27 |
| Max. Negotiated Rate |
$1,068.75 |
| Rate for Payer: Aetna Commercial |
$1,045.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$999.04
|
| Rate for Payer: Aetna Managed Medicare |
$325.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$755.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$580.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$557.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$615.69
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,068.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$650.09
|
| Rate for Payer: Health EOS Commercial |
$1,033.90
|
| Rate for Payer: HFN Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$871.26
|
| Rate for Payer: Multiplan Commercial |
$929.34
|
| Rate for Payer: NAPHCARE Commercial |
$697.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,068.75
|
| Rate for Payer: Quartz Beloit One Network |
$569.22
|
| Rate for Payer: Quartz Commercial |
$755.09
|
| Rate for Payer: Quartz Medicare Advantage |
$697.01
|
| Rate for Payer: The Alliance Commercial |
$580.84
|
| Rate for Payer: WEA Trust Commercial |
$638.92
|
| Rate for Payer: WPS Commercial |
$860.43
|
|
|
TOGA FLYTE XXL 0408-840-000
|
Facility
|
IP
|
$1,117.00
|
|
| Hospital Charge Code |
2966090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$569.22 |
| Max. Negotiated Rate |
$1,068.75 |
| Rate for Payer: Aetna Commercial |
$1,045.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$999.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$615.69
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,068.75
|
| Rate for Payer: Health EOS Commercial |
$1,033.90
|
| Rate for Payer: HFN Commercial |
$1,068.75
|
| Rate for Payer: Multiplan Commercial |
$929.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,068.75
|
| Rate for Payer: Quartz Beloit One Network |
$569.22
|
| Rate for Payer: Quartz Commercial |
$697.01
|
| Rate for Payer: WEA Trust Commercial |
$638.92
|
| Rate for Payer: WPS Commercial |
$860.43
|
|
|
TOGA FLYTE XXL PEEL-AWAY 0408-840-100
|
Facility
|
IP
|
$1,811.00
|
|
| Hospital Charge Code |
4520105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$922.89 |
| Max. Negotiated Rate |
$1,732.76 |
| Rate for Payer: Aetna Commercial |
$1,695.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,619.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$998.22
|
| Rate for Payer: Cash Price |
$543.30
|
| Rate for Payer: Cigna Commercial |
$1,732.76
|
| Rate for Payer: Health EOS Commercial |
$1,676.26
|
| Rate for Payer: HFN Commercial |
$1,732.76
|
| Rate for Payer: Multiplan Commercial |
$1,506.75
|
| Rate for Payer: Preferred Network Access Commercial |
$1,732.76
|
| Rate for Payer: Quartz Beloit One Network |
$922.89
|
| Rate for Payer: Quartz Commercial |
$1,130.06
|
| Rate for Payer: WEA Trust Commercial |
$1,035.89
|
| Rate for Payer: WPS Commercial |
$1,395.01
|
|
|
TOGA FLYTE XXL PEEL-AWAY 0408-840-100
|
Facility
|
OP
|
$1,811.00
|
|
| Hospital Charge Code |
4520105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$527.36 |
| Max. Negotiated Rate |
$1,732.76 |
| Rate for Payer: Aetna Commercial |
$1,695.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,619.76
|
| Rate for Payer: Aetna Managed Medicare |
$527.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,224.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$941.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$904.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$998.22
|
| Rate for Payer: Cash Price |
$543.30
|
| Rate for Payer: Cigna Commercial |
$1,732.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,054.00
|
| Rate for Payer: Health EOS Commercial |
$1,676.26
|
| Rate for Payer: HFN Commercial |
$1,732.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,412.58
|
| Rate for Payer: Multiplan Commercial |
$1,506.75
|
| Rate for Payer: NAPHCARE Commercial |
$1,130.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,732.76
|
| Rate for Payer: Quartz Beloit One Network |
$922.89
|
| Rate for Payer: Quartz Commercial |
$1,224.24
|
| Rate for Payer: Quartz Medicare Advantage |
$1,130.06
|
| Rate for Payer: The Alliance Commercial |
$941.72
|
| Rate for Payer: WEA Trust Commercial |
$1,035.89
|
| Rate for Payer: WPS Commercial |
$1,395.01
|
|
