|
BONE SCREW 60MM 6250-65-60
|
Facility
|
OP
|
$1,144.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$320.32 |
| Max. Negotiated Rate |
$4,576.00 |
| Rate for Payer: Aetna Commercial |
$1,029.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$983.84
|
| Rate for Payer: Aetna Managed Medicare |
$320.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$743.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$572.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$549.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$606.32
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cigna Commercial |
$1,052.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$640.18
|
| Rate for Payer: Health EOS Commercial |
$1,018.16
|
| Rate for Payer: HFN Commercial |
$1,052.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$858.00
|
| Rate for Payer: Multiplan Commercial |
$915.20
|
| Rate for Payer: NAPHCARE Commercial |
$686.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,052.48
|
| Rate for Payer: Quartz Beloit One Network |
$560.56
|
| Rate for Payer: Quartz Commercial |
$743.60
|
| Rate for Payer: Quartz Medicare Advantage |
$686.40
|
| Rate for Payer: The Alliance Commercial |
$4,576.00
|
| Rate for Payer: WEA Trust Commercial |
$629.20
|
| Rate for Payer: WPS Commercial |
$847.36
|
|
|
BONE SCREW LOW PROFILE HEX 6.5 X 30MM 7030-6530
|
Facility
|
IP
|
$753.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5659659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$368.97 |
| Max. Negotiated Rate |
$692.76 |
| Rate for Payer: Aetna Commercial |
$677.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$647.58
|
| 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
|
|
|
BONE SCREW LOW PROFILE HEX 6.5 X 30MM 7030-6530
|
Facility
|
OP
|
$753.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5659659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$210.84 |
| 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 |
$489.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$376.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$361.44
|
| 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: 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
|
|
|
BONE SCREW TORX 6.5 X 20MM 2030-6520-1
|
Facility
|
IP
|
$952.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3297464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$466.48 |
| Max. Negotiated Rate |
$875.84 |
| Rate for Payer: Aetna Commercial |
$856.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.56
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$875.84
|
| Rate for Payer: Health EOS Commercial |
$847.28
|
| Rate for Payer: HFN Commercial |
$875.84
|
| Rate for Payer: Multiplan Commercial |
$761.60
|
| Rate for Payer: NAPHCARE Commercial |
$571.20
|
| Rate for Payer: Preferred Network Access Commercial |
$875.84
|
| Rate for Payer: Quartz Beloit One Network |
$466.48
|
| Rate for Payer: Quartz Commercial |
$571.20
|
| Rate for Payer: WEA Trust Commercial |
$523.60
|
| Rate for Payer: WPS Commercial |
$705.15
|
|
|
BONE SCREW TORX 6.5 X 20MM 2030-6520-1
|
Facility
|
OP
|
$952.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3297464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.56 |
| Max. Negotiated Rate |
$3,808.00 |
| Rate for Payer: Aetna Commercial |
$856.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.72
|
| Rate for Payer: Aetna Managed Medicare |
$266.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$476.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.56
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$875.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.74
|
| Rate for Payer: Health EOS Commercial |
$847.28
|
| Rate for Payer: HFN Commercial |
$875.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$714.00
|
| Rate for Payer: Multiplan Commercial |
$761.60
|
| Rate for Payer: NAPHCARE Commercial |
$571.20
|
| Rate for Payer: Preferred Network Access Commercial |
$875.84
|
| Rate for Payer: Quartz Beloit One Network |
$466.48
|
| Rate for Payer: Quartz Commercial |
$618.80
|
| Rate for Payer: Quartz Medicare Advantage |
$571.20
|
| Rate for Payer: The Alliance Commercial |
$3,808.00
|
| Rate for Payer: WEA Trust Commercial |
$523.60
|
| Rate for Payer: WPS Commercial |
$705.15
|
|
|
BONE SCREW TORX 6.5 X 25MM 2030-6525-1
|
Facility
|
IP
|
$951.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3127480
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.99 |
| Max. Negotiated Rate |
$874.92 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$570.60
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
BONE SCREW TORX 6.5 X 25MM 2030-6525-1
|
Facility
|
OP
|
$951.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3127480
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.28 |
| Max. Negotiated Rate |
$3,804.00 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Aetna Managed Medicare |
$266.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.18
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.25
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$618.15
|
| Rate for Payer: Quartz Medicare Advantage |
$570.60
|
| Rate for Payer: The Alliance Commercial |
$3,804.00
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
BONE SCREW TORX 6.5 X 30MM 2030-6530-1
|
Facility
|
IP
|
$951.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3297465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.99 |
| Max. Negotiated Rate |
$874.92 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$570.60
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
BONE SCREW TORX 6.5 X 30MM 2030-6530-1
|
Facility
|
OP
|
$951.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3297465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.28 |
| Max. Negotiated Rate |
$3,804.00 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Aetna Managed Medicare |
$266.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.18
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.25
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$618.15
|
| Rate for Payer: Quartz Medicare Advantage |
$570.60
|
| Rate for Payer: The Alliance Commercial |
$3,804.00
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
BONE SCREW TORX 6.5 X 35MM 2030-6535-1
|
Facility
|
IP
|
$916.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5074614
|
|
Hospital Revenue Code
|
273
|
| Min. Negotiated Rate |
$448.84 |
| Max. Negotiated Rate |
$842.72 |
| Rate for Payer: Aetna Commercial |
$824.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$787.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$485.48
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$842.72
|
| Rate for Payer: Health EOS Commercial |
$815.24
|
| Rate for Payer: HFN Commercial |
$842.72
|
| Rate for Payer: Multiplan Commercial |
$732.80
|
| Rate for Payer: NAPHCARE Commercial |
$549.60
|
| Rate for Payer: Preferred Network Access Commercial |
$842.72
|
| Rate for Payer: Quartz Beloit One Network |
$448.84
|
| Rate for Payer: Quartz Commercial |
$549.60
|
| Rate for Payer: WEA Trust Commercial |
$503.80
|
| Rate for Payer: WPS Commercial |
$678.48
|
|
|
BONE SCREW TORX 6.5 X 35MM 2030-6535-1
|
Facility
|
OP
|
$916.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5074614
|
|
Hospital Revenue Code
|
273
|
| Min. Negotiated Rate |
$256.48 |
| Max. Negotiated Rate |
$3,664.00 |
| Rate for Payer: Aetna Commercial |
$824.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$787.76
|
| Rate for Payer: Aetna Managed Medicare |
$256.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$595.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$458.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$485.48
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$842.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.59
|
| Rate for Payer: Health EOS Commercial |
$815.24
|
| Rate for Payer: HFN Commercial |
$842.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$687.00
|
| Rate for Payer: Multiplan Commercial |
$732.80
|
| Rate for Payer: NAPHCARE Commercial |
$549.60
|
| Rate for Payer: Preferred Network Access Commercial |
$842.72
|
| Rate for Payer: Quartz Beloit One Network |
$448.84
|
| Rate for Payer: Quartz Commercial |
$595.40
|
| Rate for Payer: Quartz Medicare Advantage |
$549.60
|
| Rate for Payer: The Alliance Commercial |
$3,664.00
|
| Rate for Payer: WEA Trust Commercial |
$503.80
|
| Rate for Payer: WPS Commercial |
$678.48
|
|
|
BO Neutralization Pretreatment
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 86977
|
| Hospital Charge Code |
980082
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$63.48 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$41.40
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$41.40
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
BO Neutralization Pretreatment
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 86977
|
| Hospital Charge Code |
980082
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$675.28 |
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$44.85
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.24
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$51.75
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
Boniva 1 mg Charge
|
Facility
|
OP
|
$2,459.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
2958916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.96 |
| Max. Negotiated Rate |
$9,836.00 |
| Rate for Payer: Aetna Commercial |
$2,213.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,114.74
|
| Rate for Payer: Aetna Managed Medicare |
$688.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,598.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,229.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,180.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,303.27
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cigna Commercial |
$2,262.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.96
|
| Rate for Payer: Health EOS Commercial |
$2,188.51
|
| Rate for Payer: HFN Commercial |
$2,262.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,844.25
|
| Rate for Payer: Multiplan Commercial |
$1,967.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,475.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,262.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,204.91
|
| Rate for Payer: Quartz Commercial |
$1,598.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,475.40
|
| Rate for Payer: The Alliance Commercial |
$9,836.00
|
| Rate for Payer: WEA Trust Commercial |
$1,352.45
|
| Rate for Payer: WPS Commercial |
$79.28
|
|
|
Boniva 1 mg Charge
|
Professional
|
Both
|
$2,459.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
2958916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$2,336.05 |
| Rate for Payer: Aetna Commercial |
$2,336.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,114.74
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cigna Commercial |
$2,336.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.71
|
| Rate for Payer: Health EOS Commercial |
$2,237.69
|
| Rate for Payer: HFN Commercial |
$2,336.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.28
|
| Rate for Payer: Multiplan Commercial |
$1,967.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,336.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,081.96
|
| Rate for Payer: Quartz Commercial |
$1,401.63
|
| Rate for Payer: The Alliance Commercial |
$1,229.50
|
| Rate for Payer: United Healthcare Medicaid |
$25.60
|
| Rate for Payer: WEA Trust Commercial |
$1,352.45
|
| Rate for Payer: WPS Commercial |
$79.28
|
|
|
Boniva 1 mg Charge
|
Facility
|
IP
|
$2,459.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
2958916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,204.91 |
| Max. Negotiated Rate |
$2,262.28 |
| Rate for Payer: Aetna Commercial |
$2,213.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,114.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,303.27
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cigna Commercial |
$2,262.28
|
| Rate for Payer: Health EOS Commercial |
$2,188.51
|
| Rate for Payer: HFN Commercial |
$2,262.28
|
| Rate for Payer: Multiplan Commercial |
$1,967.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,475.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,262.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,204.91
|
| Rate for Payer: Quartz Commercial |
$1,475.40
|
| Rate for Payer: WEA Trust Commercial |
$1,352.45
|
| Rate for Payer: WPS Commercial |
$1,821.38
|
|
|
BOOT HEEL SOF CARE ONE SIZE
|
Facility
|
IP
|
$292.00
|
|
| Hospital Charge Code |
2963768
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$143.08 |
| Max. Negotiated Rate |
$268.64 |
| Rate for Payer: Aetna Commercial |
$262.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.76
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$268.64
|
| Rate for Payer: Health EOS Commercial |
$259.88
|
| Rate for Payer: HFN Commercial |
$268.64
|
| Rate for Payer: Multiplan Commercial |
$233.60
|
| Rate for Payer: NAPHCARE Commercial |
$175.20
|
| Rate for Payer: Preferred Network Access Commercial |
$268.64
|
| Rate for Payer: Quartz Beloit One Network |
$143.08
|
| Rate for Payer: Quartz Commercial |
$175.20
|
| Rate for Payer: WEA Trust Commercial |
$160.60
|
| Rate for Payer: WPS Commercial |
$216.28
|
|
|
BOOT HEEL SOF CARE ONE SIZE
|
Facility
|
OP
|
$292.00
|
|
| Hospital Charge Code |
2963768
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.76 |
| Max. Negotiated Rate |
$1,168.00 |
| Rate for Payer: Aetna Commercial |
$262.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.12
|
| Rate for Payer: Aetna Managed Medicare |
$81.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$189.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$146.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$140.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.76
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$268.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.40
|
| Rate for Payer: Health EOS Commercial |
$259.88
|
| Rate for Payer: HFN Commercial |
$268.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$219.00
|
| Rate for Payer: Multiplan Commercial |
$233.60
|
| Rate for Payer: NAPHCARE Commercial |
$175.20
|
| Rate for Payer: Preferred Network Access Commercial |
$268.64
|
| Rate for Payer: Quartz Beloit One Network |
$143.08
|
| Rate for Payer: Quartz Commercial |
$189.80
|
| Rate for Payer: Quartz Medicare Advantage |
$175.20
|
| Rate for Payer: The Alliance Commercial |
$1,168.00
|
| Rate for Payer: WEA Trust Commercial |
$160.60
|
| Rate for Payer: WPS Commercial |
$216.28
|
|
|
BOOT MATRIAX AIR WALKER LARGE
|
Facility
|
IP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969752
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$368.97 |
| Max. Negotiated Rate |
$692.76 |
| Rate for Payer: Aetna Commercial |
$677.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$647.58
|
| 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 MATRIAX AIR WALKER LARGE
|
Facility
|
OP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969752
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$647.58
|
| 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 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 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 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: Aetna Gatekeeper/Not Gatekeeper |
$647.58
|
| 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 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
|
|
