|
BOOT MAXTRAX AIR WALKER MEDIUM
|
Facility
OP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969753
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$153.09 |
| Max. Negotiated Rate |
$3,012.00 |
| Rate for Payer: Aetna Commercial |
$677.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$647.58
|
| Rate for Payer: Aetna Managed Medicare |
$210.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$153.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$153.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$153.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.09
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$692.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$421.38
|
| Rate for Payer: Health EOS Commercial |
$670.17
|
| Rate for Payer: HFN Commercial |
$692.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$564.75
|
| Rate for Payer: Multiplan Commercial |
$602.40
|
| Rate for Payer: NAPHCARE Commercial |
$451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$692.76
|
| Rate for Payer: Quartz Beloit One Network |
$368.97
|
| Rate for Payer: Quartz Commercial |
$489.45
|
| Rate for Payer: Quartz Medicare Advantage |
$451.80
|
| Rate for Payer: The Alliance Commercial |
$3,012.00
|
| Rate for Payer: WEA Trust Commercial |
$414.15
|
| Rate for Payer: WPS Commercial |
$557.75
|
|
|
BOOT MAXTRAX AIR WALKER MEDIUM
|
Facility
IP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969753
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$368.97 |
| Max. Negotiated Rate |
$692.76 |
| Rate for Payer: Aetna Commercial |
$677.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.09
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$692.76
|
| Rate for Payer: Health EOS Commercial |
$670.17
|
| Rate for Payer: HFN Commercial |
$692.76
|
| Rate for Payer: Multiplan Commercial |
$602.40
|
| Rate for Payer: NAPHCARE Commercial |
$451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$692.76
|
| Rate for Payer: Quartz Beloit One Network |
$368.97
|
| Rate for Payer: Quartz Commercial |
$451.80
|
| Rate for Payer: WEA Trust Commercial |
$414.15
|
| Rate for Payer: WPS Commercial |
$557.75
|
|
|
BOOT MAXTRAX AIR WALKER SMALL
|
Facility
IP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969751
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$368.97 |
| Max. Negotiated Rate |
$692.76 |
| Rate for Payer: Aetna Commercial |
$677.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.09
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$692.76
|
| Rate for Payer: Health EOS Commercial |
$670.17
|
| Rate for Payer: HFN Commercial |
$692.76
|
| Rate for Payer: Multiplan Commercial |
$602.40
|
| Rate for Payer: NAPHCARE Commercial |
$451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$692.76
|
| Rate for Payer: Quartz Beloit One Network |
$368.97
|
| Rate for Payer: Quartz Commercial |
$451.80
|
| Rate for Payer: WEA Trust Commercial |
$414.15
|
| Rate for Payer: WPS Commercial |
$557.75
|
|
|
BOOT MAXTRAX AIR WALKER SMALL
|
Facility
OP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969751
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$153.09 |
| Max. Negotiated Rate |
$3,012.00 |
| Rate for Payer: Aetna Commercial |
$677.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$647.58
|
| Rate for Payer: Aetna Managed Medicare |
$210.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$153.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$153.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$153.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.09
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$692.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$421.38
|
| Rate for Payer: Health EOS Commercial |
$670.17
|
| Rate for Payer: HFN Commercial |
$692.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$564.75
|
| Rate for Payer: Multiplan Commercial |
$602.40
|
| Rate for Payer: NAPHCARE Commercial |
$451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$692.76
|
| Rate for Payer: Quartz Beloit One Network |
$368.97
|
| Rate for Payer: Quartz Commercial |
$489.45
|
| Rate for Payer: Quartz Medicare Advantage |
$451.80
|
| Rate for Payer: The Alliance Commercial |
$3,012.00
|
| Rate for Payer: WEA Trust Commercial |
$414.15
|
| Rate for Payer: WPS Commercial |
$557.75
|
|
|
BOOT SLIMLINE CAST CHILD LG 2039-00
|
Facility
OP
|
$329.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2974382
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$1,316.00 |
| Rate for Payer: Aetna Commercial |
$296.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$282.94
|
| Rate for Payer: Aetna Managed Medicare |
$92.12
|
| 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 |
$174.37
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cigna Commercial |
$302.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.11
|
| Rate for Payer: Health EOS Commercial |
$292.81
|
| Rate for Payer: HFN Commercial |
$302.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$246.75
|
| Rate for Payer: Multiplan Commercial |
$263.20
|
| Rate for Payer: NAPHCARE Commercial |
$197.40
|
| Rate for Payer: Preferred Network Access Commercial |
$302.68
|
| Rate for Payer: Quartz Beloit One Network |
$161.21
|
| Rate for Payer: Quartz Commercial |
$213.85
|
| Rate for Payer: Quartz Medicare Advantage |
$197.40
|
| Rate for Payer: The Alliance Commercial |
$1,316.00
|
| Rate for Payer: WEA Trust Commercial |
$180.95
|
| Rate for Payer: WPS Commercial |
$243.69
|
|
|
BOOT SLIMLINE CAST CHILD LG 2039-00
|
Facility
IP
|
$329.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2974382
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$161.21 |
| Max. Negotiated Rate |
$302.68 |
| Rate for Payer: Aetna Commercial |
$296.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.37
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cigna Commercial |
$302.68
|
| Rate for Payer: Health EOS Commercial |
$292.81
|
| Rate for Payer: HFN Commercial |
$302.68
|
| Rate for Payer: Multiplan Commercial |
$263.20
|
| Rate for Payer: NAPHCARE Commercial |
$197.40
|
| Rate for Payer: Preferred Network Access Commercial |
$302.68
|
| Rate for Payer: Quartz Beloit One Network |
$161.21
|
| Rate for Payer: Quartz Commercial |
$197.40
|
| Rate for Payer: WEA Trust Commercial |
$180.95
|
| Rate for Payer: WPS Commercial |
$243.69
|
|
|
BOOT SLIMLINE CAST CHILD MED 2039-99
|
Facility
OP
|
$2,105.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2965324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$8,420.00 |
| Rate for Payer: Aetna Commercial |
$1,894.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,810.30
|
| Rate for Payer: Aetna Managed Medicare |
$589.40
|
| 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 |
$1,115.65
|
| Rate for Payer: Cash Price |
$631.50
|
| Rate for Payer: Cash Price |
$631.50
|
| Rate for Payer: Cigna Commercial |
$1,936.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,177.96
|
| Rate for Payer: Health EOS Commercial |
$1,873.45
|
| Rate for Payer: HFN Commercial |
$1,936.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,578.75
|
| Rate for Payer: Multiplan Commercial |
$1,684.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,263.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,936.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,031.45
|
| Rate for Payer: Quartz Commercial |
$1,368.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,263.00
|
| Rate for Payer: The Alliance Commercial |
$8,420.00
|
| Rate for Payer: WEA Trust Commercial |
$1,157.75
|
| Rate for Payer: WPS Commercial |
$1,559.17
|
|
|
BOOT SLIMLINE CAST CHILD MED 2039-99
|
Facility
IP
|
$2,105.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2965324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,031.45 |
| Max. Negotiated Rate |
$1,936.60 |
| Rate for Payer: Aetna Commercial |
$1,894.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,115.65
|
| Rate for Payer: Cash Price |
$631.50
|
| Rate for Payer: Cigna Commercial |
$1,936.60
|
| Rate for Payer: Health EOS Commercial |
$1,873.45
|
| Rate for Payer: HFN Commercial |
$1,936.60
|
| Rate for Payer: Multiplan Commercial |
$1,684.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,263.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,936.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,031.45
|
| Rate for Payer: Quartz Commercial |
$1,263.00
|
| Rate for Payer: WEA Trust Commercial |
$1,157.75
|
| Rate for Payer: WPS Commercial |
$1,559.17
|
|
|
BOOT SLIMLINE CAST LARGE 2039-04
|
Facility
IP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963849
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST LARGE 2039-04
|
Facility
OP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963849
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| 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 |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST MEDIUM 2039-03
|
Facility
IP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963850
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST MEDIUM 2039-03
|
Facility
OP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963850
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| 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 |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST SMALL 2039-02
|
Facility
IP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963851
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST SMALL 2039-02
|
Facility
OP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963851
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| 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 |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST X-LARGE 2039-05
|
Facility
IP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2974381
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST X-LARGE 2039-05
|
Facility
OP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2974381
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| 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 |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST X-SMALL 2039-01
|
Facility
OP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963852
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| 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 |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT SLIMLINE CAST X-SMALL 2039-01
|
Facility
IP
|
$334.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
2963852
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
BOOT TRACTION UNIVERSAL ORT31100
|
Facility
OP
|
$349.00
|
|
| Hospital Charge Code |
2963897
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.72 |
| Max. Negotiated Rate |
$1,396.00 |
| Rate for Payer: Aetna Commercial |
$314.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$300.14
|
| Rate for Payer: Aetna Managed Medicare |
$97.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$174.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$167.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.97
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$321.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$195.30
|
| Rate for Payer: Health EOS Commercial |
$310.61
|
| Rate for Payer: HFN Commercial |
$321.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$261.75
|
| Rate for Payer: Multiplan Commercial |
$279.20
|
| Rate for Payer: NAPHCARE Commercial |
$209.40
|
| Rate for Payer: Preferred Network Access Commercial |
$321.08
|
| Rate for Payer: Quartz Beloit One Network |
$171.01
|
| Rate for Payer: Quartz Commercial |
$226.85
|
| Rate for Payer: Quartz Medicare Advantage |
$209.40
|
| Rate for Payer: The Alliance Commercial |
$1,396.00
|
| Rate for Payer: WEA Trust Commercial |
$191.95
|
| Rate for Payer: WPS Commercial |
$258.50
|
|
|
BOOT TRACTION UNIVERSAL ORT31100
|
Facility
IP
|
$349.00
|
|
| Hospital Charge Code |
2963897
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$171.01 |
| Max. Negotiated Rate |
$321.08 |
| Rate for Payer: Aetna Commercial |
$314.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.97
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$321.08
|
| Rate for Payer: Health EOS Commercial |
$310.61
|
| Rate for Payer: HFN Commercial |
$321.08
|
| Rate for Payer: Multiplan Commercial |
$279.20
|
| Rate for Payer: NAPHCARE Commercial |
$209.40
|
| Rate for Payer: Preferred Network Access Commercial |
$321.08
|
| Rate for Payer: Quartz Beloit One Network |
$171.01
|
| Rate for Payer: Quartz Commercial |
$209.40
|
| Rate for Payer: WEA Trust Commercial |
$191.95
|
| Rate for Payer: WPS Commercial |
$258.50
|
|
|
BO Platelet Crossmatch
|
Facility
IP
|
$616.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
987763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$301.84 |
| Max. Negotiated Rate |
$566.72 |
| Rate for Payer: Aetna Commercial |
$554.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$326.48
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cigna Commercial |
$566.72
|
| Rate for Payer: Health EOS Commercial |
$548.24
|
| Rate for Payer: HFN Commercial |
$566.72
|
| Rate for Payer: Multiplan Commercial |
$492.80
|
| Rate for Payer: NAPHCARE Commercial |
$369.60
|
| Rate for Payer: Preferred Network Access Commercial |
$566.72
|
| Rate for Payer: Quartz Beloit One Network |
$301.84
|
| Rate for Payer: Quartz Commercial |
$369.60
|
| Rate for Payer: WEA Trust Commercial |
$338.80
|
| Rate for Payer: WPS Commercial |
$456.27
|
|
|
BO Platelet Crossmatch
|
Facility
OP
|
$616.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
987763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.37 |
| Max. Negotiated Rate |
$2,464.00 |
| Rate for Payer: Aetna Commercial |
$554.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$529.76
|
| Rate for Payer: Aetna Managed Medicare |
$18.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.15
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.49
|
| Rate for Payer: Anthem Medicaid |
$18.98
|
| Rate for Payer: Anthem Medicare Advantage |
$18.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$326.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.37
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cigna Commercial |
$566.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.98
|
| Rate for Payer: Dean Health Medicaid |
$18.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.37
|
| Rate for Payer: Health EOS Commercial |
$548.24
|
| Rate for Payer: HFN Commercial |
$566.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.37
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.37
|
| Rate for Payer: Managed Health Services Medicaid |
$19.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.37
|
| Rate for Payer: Multiplan Commercial |
$492.80
|
| Rate for Payer: NAPHCARE Commercial |
$27.56
|
| Rate for Payer: Preferred Network Access Commercial |
$566.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.98
|
| Rate for Payer: Quartz Beloit One Network |
$301.84
|
| Rate for Payer: Quartz Commercial |
$400.40
|
| Rate for Payer: Quartz Medicare Advantage |
$18.37
|
| Rate for Payer: The Alliance Commercial |
$2,464.00
|
| Rate for Payer: United Healthcare Medicaid |
$18.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.37
|
| Rate for Payer: United Healthcare PPO |
$462.00
|
| Rate for Payer: WEA Trust Commercial |
$338.80
|
| Rate for Payer: Wellcare Medicare |
$18.37
|
| Rate for Payer: WMAP Medicaid |
$18.98
|
| Rate for Payer: WPS Commercial |
$456.27
|
|
|
Bordetella pertussis/parapertussis Culture
|
Facility
OP
|
$191.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
633885
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$764.00 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Aetna Managed Medicare |
$6.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.01
|
| Rate for Payer: Anthem Medicaid |
$6.85
|
| Rate for Payer: Anthem Medicare Advantage |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.63
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.85
|
| Rate for Payer: Dean Health Medicaid |
$6.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.63
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.63
|
| Rate for Payer: Managed Health Services Medicaid |
$7.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.63
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$9.94
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6.85
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$124.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6.63
|
| Rate for Payer: The Alliance Commercial |
$764.00
|
| Rate for Payer: United Healthcare Medicaid |
$6.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.63
|
| Rate for Payer: United Healthcare PPO |
$143.25
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: Wellcare Medicare |
$6.63
|
| Rate for Payer: WMAP Medicaid |
$6.85
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Bordetella pertussis/parapertussis Culture
|
Facility
IP
|
$191.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
633885
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$175.72 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$114.60
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Bordetella pertussis/parapertussis Culture
|
Professional
|
$191.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
633885
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Aetna Commercial |
$181.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Aetna Managed Medicare |
$6.63
|
| Rate for Payer: Anthem Medicare Advantage |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.63
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$181.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$95.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.63
|
| Rate for Payer: Health EOS Commercial |
$173.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.63
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: Preferred Network Access Commercial |
$181.45
|
| Rate for Payer: Quartz Beloit One Network |
$84.04
|
| Rate for Payer: Quartz Commercial |
$108.87
|
| Rate for Payer: Quartz Medicare Advantage |
$6.63
|
| Rate for Payer: The Alliance Commercial |
$26.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.63
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$29.17
|
|
