|
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: Aetna Gatekeeper/Not Gatekeeper |
$282.94
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,810.30
|
| 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 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 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: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| 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
|
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-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: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| 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-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: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| 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-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 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: Aetna Gatekeeper/Not Gatekeeper |
$300.14
|
| 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
|
|
|
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
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$529.76
|
| 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 |
$566.72 |
| 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 DHI/DHP/ASO |
$344.71
|
| 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 |
$73.48
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| 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
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
633885
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$175.72 |
| 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 DHI/DHP/ASO |
$106.88
|
| 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 |
$26.52
|
| 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
|
Professional
|
Both
|
$191.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
633885
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Aetna Commercial |
$181.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| 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 |
$114.60
|
| Rate for Payer: Health EOS Commercial |
$173.81
|
| Rate for Payer: HFN Commercial |
$181.45
|
| 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: 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: The Alliance Commercial |
$95.50
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Bordetella pertussis/parapertussis PCR
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
983497
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.98 |
| Max. Negotiated Rate |
$185.84 |
| Rate for Payer: Aetna Commercial |
$181.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$107.06
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$185.84
|
| Rate for Payer: Health EOS Commercial |
$179.78
|
| Rate for Payer: HFN Commercial |
$185.84
|
| Rate for Payer: Multiplan Commercial |
$161.60
|
| Rate for Payer: NAPHCARE Commercial |
$121.20
|
| Rate for Payer: Preferred Network Access Commercial |
$185.84
|
| Rate for Payer: Quartz Beloit One Network |
$98.98
|
| Rate for Payer: Quartz Commercial |
$121.20
|
| Rate for Payer: WEA Trust Commercial |
$111.10
|
| Rate for Payer: WPS Commercial |
$149.62
|
|
|
Bordetella pertussis/parapertussis PCR
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
983497
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$185.84 |
| Rate for Payer: Aetna Commercial |
$181.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.72
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$107.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$185.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$113.04
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$179.78
|
| Rate for Payer: HFN Commercial |
$185.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$161.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$185.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$98.98
|
| Rate for Payer: Quartz Commercial |
$131.30
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$151.50
|
| Rate for Payer: WEA Trust Commercial |
$111.10
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$149.62
|
|
|
Bordetella pertussis/parapertussis PCR
|
Professional
|
Both
|
$202.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
983497
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$88.88 |
| Max. Negotiated Rate |
$191.90 |
| Rate for Payer: Aetna Commercial |
$191.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.72
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$191.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$101.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.20
|
| Rate for Payer: Health EOS Commercial |
$183.82
|
| Rate for Payer: HFN Commercial |
$191.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$161.60
|
| Rate for Payer: Preferred Network Access Commercial |
$191.90
|
| Rate for Payer: Quartz Beloit One Network |
$88.88
|
| Rate for Payer: Quartz Commercial |
$115.14
|
| Rate for Payer: The Alliance Commercial |
$101.00
|
| Rate for Payer: WEA Trust Commercial |
$111.10
|
| Rate for Payer: WPS Commercial |
$149.62
|
|
|
BO Ref Emergency Consultation
|
Facility
|
IP
|
$1,101.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
980083
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$539.49 |
| Max. Negotiated Rate |
$1,012.92 |
| Rate for Payer: Aetna Commercial |
$990.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$946.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$583.53
|
| Rate for Payer: Cash Price |
$330.30
|
| Rate for Payer: Cigna Commercial |
$1,012.92
|
| Rate for Payer: Health EOS Commercial |
$979.89
|
| Rate for Payer: HFN Commercial |
$1,012.92
|
| Rate for Payer: Multiplan Commercial |
$880.80
|
| Rate for Payer: NAPHCARE Commercial |
$660.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,012.92
|
| Rate for Payer: Quartz Beloit One Network |
$539.49
|
| Rate for Payer: Quartz Commercial |
$660.60
|
| Rate for Payer: WEA Trust Commercial |
$605.55
|
| Rate for Payer: WPS Commercial |
$815.51
|
|
|
BO Ref Emergency Consultation
|
Facility
|
OP
|
$1,101.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
980083
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$29.43 |
| Max. Negotiated Rate |
$1,012.92 |
| Rate for Payer: Aetna Commercial |
$990.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$946.86
|
| Rate for Payer: Aetna Managed Medicare |
$29.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$715.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$550.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$528.48
|
| Rate for Payer: Anthem Medicare Advantage |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$583.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.43
|
| Rate for Payer: Cash Price |
$330.30
|
| Rate for Payer: Cash Price |
$330.30
|
| Rate for Payer: Cigna Commercial |
$1,012.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$616.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29.43
|
| Rate for Payer: Health EOS Commercial |
$979.89
|
| Rate for Payer: HFN Commercial |
$1,012.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29.43
|
| Rate for Payer: Multiplan Commercial |
$880.80
|
| Rate for Payer: NAPHCARE Commercial |
$44.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,012.92
|
| Rate for Payer: Quartz Beloit One Network |
$539.49
|
| Rate for Payer: Quartz Commercial |
$715.65
|
| Rate for Payer: Quartz Medicare Advantage |
$29.43
|
| Rate for Payer: The Alliance Commercial |
$117.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.43
|
| Rate for Payer: United Healthcare PPO |
$825.75
|
| Rate for Payer: WEA Trust Commercial |
$605.55
|
| Rate for Payer: Wellcare Medicare |
$29.43
|
| Rate for Payer: WPS Commercial |
$815.51
|
|
