|
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 |
$466.79 |
| Max. Negotiated Rate |
$876.43 |
| Rate for Payer: Aetna Commercial |
$857.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$819.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.90
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$876.43
|
| Rate for Payer: Health EOS Commercial |
$847.85
|
| Rate for Payer: HFN Commercial |
$876.43
|
| Rate for Payer: Multiplan Commercial |
$762.11
|
| Rate for Payer: Preferred Network Access Commercial |
$876.43
|
| Rate for Payer: Quartz Beloit One Network |
$466.79
|
| Rate for Payer: Quartz Commercial |
$571.58
|
| Rate for Payer: WEA Trust Commercial |
$523.95
|
| Rate for Payer: WPS Commercial |
$705.59
|
|
|
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 |
$266.74 |
| Max. Negotiated Rate |
$876.43 |
| Rate for Payer: Aetna Commercial |
$857.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$819.27
|
| Rate for Payer: Aetna Managed Medicare |
$266.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$619.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$476.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$457.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.90
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$876.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$533.11
|
| Rate for Payer: Health EOS Commercial |
$847.85
|
| Rate for Payer: HFN Commercial |
$876.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$714.48
|
| Rate for Payer: Multiplan Commercial |
$762.11
|
| Rate for Payer: NAPHCARE Commercial |
$571.58
|
| Rate for Payer: Preferred Network Access Commercial |
$876.43
|
| Rate for Payer: Quartz Beloit One Network |
$466.79
|
| Rate for Payer: Quartz Commercial |
$619.22
|
| Rate for Payer: Quartz Medicare Advantage |
$571.58
|
| Rate for Payer: The Alliance Commercial |
$476.32
|
| Rate for Payer: WEA Trust Commercial |
$523.95
|
| Rate for Payer: WPS Commercial |
$705.59
|
|
|
BO Neutralization Pretreatment
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 86977
|
| Hospital Charge Code |
980082
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$66.02 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: Preferred Network Access Commercial |
$66.02
|
| Rate for Payer: Quartz Beloit One Network |
$35.16
|
| Rate for Payer: Quartz Commercial |
$43.06
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
BO Neutralization Pretreatment
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 86977
|
| Hospital Charge Code |
980082
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$717.18 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Aetna Managed Medicare |
$179.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.45
|
| Rate for Payer: Anthem Medicare Advantage |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$179.30
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$179.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$179.30
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$179.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$179.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$179.30
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$66.02
|
| Rate for Payer: Quartz Beloit One Network |
$35.16
|
| Rate for Payer: Quartz Commercial |
$46.64
|
| Rate for Payer: Quartz Medicare Advantage |
$179.30
|
| Rate for Payer: The Alliance Commercial |
$717.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.30
|
| Rate for Payer: United Healthcare PPO |
$53.82
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: Wellcare Medicare |
$179.30
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
Boniva 1 mg Charge
|
Professional
|
Both
|
$2,459.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
2958916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.67 |
| Max. Negotiated Rate |
$2,429.49 |
| Rate for Payer: Aetna Commercial |
$2,429.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,199.33
|
| Rate for Payer: Aetna Managed Medicare |
$13.67
|
| Rate for Payer: Anthem Medicare Advantage |
$13.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.67
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cigna Commercial |
$2,429.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.98
|
| Rate for Payer: Health EOS Commercial |
$2,327.20
|
| Rate for Payer: HFN Commercial |
$2,429.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.67
|
| Rate for Payer: Multiplan Commercial |
$2,045.89
|
| Rate for Payer: NAPHCARE Commercial |
$20.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,429.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,125.24
|
| Rate for Payer: Quartz Commercial |
$1,457.70
|
| Rate for Payer: Quartz Medicare Advantage |
$13.67
|
| Rate for Payer: The Alliance Commercial |
$37.58
|
| Rate for Payer: United Healthcare Medicaid |
$13.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.67
|
| Rate for Payer: WEA Trust Commercial |
$1,406.55
|
| Rate for Payer: WPS Commercial |
$82.45
|
|
|
Boniva 1 mg Charge
|
Facility
|
OP
|
$2,459.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
2958916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.63 |
| Max. Negotiated Rate |
$2,352.77 |
| Rate for Payer: Aetna Commercial |
$2,301.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,199.33
|
| Rate for Payer: Aetna Managed Medicare |
$716.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,662.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,278.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,227.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,355.40
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cigna Commercial |
$2,352.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.63
|
| Rate for Payer: Health EOS Commercial |
$2,276.05
|
| Rate for Payer: HFN Commercial |
$2,352.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,918.02
|
| Rate for Payer: Multiplan Commercial |
$2,045.89
|
| Rate for Payer: NAPHCARE Commercial |
$1,534.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,352.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,253.11
|
| Rate for Payer: Quartz Commercial |
$1,662.28
|
| Rate for Payer: Quartz Medicare Advantage |
$1,534.42
|
| Rate for Payer: The Alliance Commercial |
$54.66
|
| Rate for Payer: WEA Trust Commercial |
$1,406.55
|
| Rate for Payer: WPS Commercial |
$82.45
|
|
|
Boniva 1 mg Charge
|
Facility
|
IP
|
$2,459.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
2958916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,253.11 |
| Max. Negotiated Rate |
$2,352.77 |
| Rate for Payer: Aetna Commercial |
$2,301.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,199.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,355.40
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cigna Commercial |
$2,352.77
|
| Rate for Payer: Health EOS Commercial |
$2,276.05
|
| Rate for Payer: HFN Commercial |
$2,352.77
|
| Rate for Payer: Multiplan Commercial |
$2,045.89
|
| Rate for Payer: Preferred Network Access Commercial |
$2,352.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,253.11
|
| Rate for Payer: Quartz Commercial |
$1,534.42
|
| Rate for Payer: WEA Trust Commercial |
$1,406.55
|
| Rate for Payer: WPS Commercial |
$1,894.17
|
|
|
BOOT HEEL SOF CARE ONE SIZE
|
Facility
|
IP
|
$292.00
|
|
| Hospital Charge Code |
2963768
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$148.80 |
| Max. Negotiated Rate |
$279.39 |
| Rate for Payer: Aetna Commercial |
$273.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$261.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.95
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$279.39
|
| Rate for Payer: Health EOS Commercial |
$270.28
|
| Rate for Payer: HFN Commercial |
$279.39
|
| Rate for Payer: Multiplan Commercial |
$242.94
|
| Rate for Payer: Preferred Network Access Commercial |
$279.39
|
| Rate for Payer: Quartz Beloit One Network |
$148.80
|
| Rate for Payer: Quartz Commercial |
$182.21
|
| Rate for Payer: WEA Trust Commercial |
$167.02
|
| Rate for Payer: WPS Commercial |
$224.93
|
|
|
BOOT HEEL SOF CARE ONE SIZE
|
Facility
|
OP
|
$292.00
|
|
| Hospital Charge Code |
2963768
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$85.03 |
| Max. Negotiated Rate |
$279.39 |
| Rate for Payer: Aetna Commercial |
$273.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$261.16
|
| Rate for Payer: Aetna Managed Medicare |
$85.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$197.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$151.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$145.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.95
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$279.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.94
|
| Rate for Payer: Health EOS Commercial |
$270.28
|
| Rate for Payer: HFN Commercial |
$279.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.76
|
| Rate for Payer: Multiplan Commercial |
$242.94
|
| Rate for Payer: NAPHCARE Commercial |
$182.21
|
| Rate for Payer: Preferred Network Access Commercial |
$279.39
|
| Rate for Payer: Quartz Beloit One Network |
$148.80
|
| Rate for Payer: Quartz Commercial |
$197.39
|
| Rate for Payer: Quartz Medicare Advantage |
$182.21
|
| Rate for Payer: The Alliance Commercial |
$151.84
|
| Rate for Payer: WEA Trust Commercial |
$167.02
|
| Rate for Payer: WPS Commercial |
$224.93
|
|
|
BOOT MATRIAX AIR WALKER LARGE
|
Facility
|
IP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969752
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$383.73 |
| Max. Negotiated Rate |
$720.47 |
| Rate for Payer: Aetna Commercial |
$704.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$673.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.05
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$720.47
|
| Rate for Payer: Health EOS Commercial |
$696.98
|
| Rate for Payer: HFN Commercial |
$720.47
|
| Rate for Payer: Multiplan Commercial |
$626.50
|
| Rate for Payer: Preferred Network Access Commercial |
$720.47
|
| Rate for Payer: Quartz Beloit One Network |
$383.73
|
| Rate for Payer: Quartz Commercial |
$469.87
|
| Rate for Payer: WEA Trust Commercial |
$430.72
|
| Rate for Payer: WPS Commercial |
$580.04
|
|
|
BOOT MATRIAX AIR WALKER LARGE
|
Facility
|
OP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969752
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$159.21 |
| Max. Negotiated Rate |
$1,323.63 |
| Rate for Payer: Aetna Commercial |
$704.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$673.48
|
| Rate for Payer: Aetna Managed Medicare |
$219.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$159.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$159.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.05
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$720.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$438.25
|
| Rate for Payer: Health EOS Commercial |
$696.98
|
| Rate for Payer: HFN Commercial |
$720.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$587.34
|
| Rate for Payer: Multiplan Commercial |
$626.50
|
| Rate for Payer: NAPHCARE Commercial |
$469.87
|
| Rate for Payer: Preferred Network Access Commercial |
$720.47
|
| Rate for Payer: Quartz Beloit One Network |
$383.73
|
| Rate for Payer: Quartz Commercial |
$509.03
|
| Rate for Payer: Quartz Medicare Advantage |
$469.87
|
| Rate for Payer: The Alliance Commercial |
$1,323.63
|
| Rate for Payer: WEA Trust Commercial |
$430.72
|
| Rate for Payer: WPS Commercial |
$580.04
|
|
|
BOOT MAXTRAX AIR WALKER MEDIUM
|
Facility
|
IP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969753
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$383.73 |
| Max. Negotiated Rate |
$720.47 |
| Rate for Payer: Aetna Commercial |
$704.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$673.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.05
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$720.47
|
| Rate for Payer: Health EOS Commercial |
$696.98
|
| Rate for Payer: HFN Commercial |
$720.47
|
| Rate for Payer: Multiplan Commercial |
$626.50
|
| Rate for Payer: Preferred Network Access Commercial |
$720.47
|
| Rate for Payer: Quartz Beloit One Network |
$383.73
|
| Rate for Payer: Quartz Commercial |
$469.87
|
| Rate for Payer: WEA Trust Commercial |
$430.72
|
| Rate for Payer: WPS Commercial |
$580.04
|
|
|
BOOT MAXTRAX AIR WALKER MEDIUM
|
Facility
|
OP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969753
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$159.21 |
| Max. Negotiated Rate |
$1,323.63 |
| Rate for Payer: Aetna Commercial |
$704.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$673.48
|
| Rate for Payer: Aetna Managed Medicare |
$219.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$159.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$159.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.05
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$720.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$438.25
|
| Rate for Payer: Health EOS Commercial |
$696.98
|
| Rate for Payer: HFN Commercial |
$720.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$587.34
|
| Rate for Payer: Multiplan Commercial |
$626.50
|
| Rate for Payer: NAPHCARE Commercial |
$469.87
|
| Rate for Payer: Preferred Network Access Commercial |
$720.47
|
| Rate for Payer: Quartz Beloit One Network |
$383.73
|
| Rate for Payer: Quartz Commercial |
$509.03
|
| Rate for Payer: Quartz Medicare Advantage |
$469.87
|
| Rate for Payer: The Alliance Commercial |
$1,323.63
|
| Rate for Payer: WEA Trust Commercial |
$430.72
|
| Rate for Payer: WPS Commercial |
$580.04
|
|
|
BOOT MAXTRAX AIR WALKER SMALL
|
Facility
|
IP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969751
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$383.73 |
| Max. Negotiated Rate |
$720.47 |
| Rate for Payer: Aetna Commercial |
$704.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$673.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.05
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$720.47
|
| Rate for Payer: Health EOS Commercial |
$696.98
|
| Rate for Payer: HFN Commercial |
$720.47
|
| Rate for Payer: Multiplan Commercial |
$626.50
|
| Rate for Payer: Preferred Network Access Commercial |
$720.47
|
| Rate for Payer: Quartz Beloit One Network |
$383.73
|
| Rate for Payer: Quartz Commercial |
$469.87
|
| Rate for Payer: WEA Trust Commercial |
$430.72
|
| Rate for Payer: WPS Commercial |
$580.04
|
|
|
BOOT MAXTRAX AIR WALKER SMALL
|
Facility
|
OP
|
$753.00
|
|
|
Service Code
|
HCPCS L4361
|
| Hospital Charge Code |
2969751
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$159.21 |
| Max. Negotiated Rate |
$1,323.63 |
| Rate for Payer: Aetna Commercial |
$704.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$673.48
|
| Rate for Payer: Aetna Managed Medicare |
$219.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$159.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$159.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$415.05
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$720.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$438.25
|
| Rate for Payer: Health EOS Commercial |
$696.98
|
| Rate for Payer: HFN Commercial |
$720.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$587.34
|
| Rate for Payer: Multiplan Commercial |
$626.50
|
| Rate for Payer: NAPHCARE Commercial |
$469.87
|
| Rate for Payer: Preferred Network Access Commercial |
$720.47
|
| Rate for Payer: Quartz Beloit One Network |
$383.73
|
| Rate for Payer: Quartz Commercial |
$509.03
|
| Rate for Payer: Quartz Medicare Advantage |
$469.87
|
| Rate for Payer: The Alliance Commercial |
$1,323.63
|
| Rate for Payer: WEA Trust Commercial |
$430.72
|
| Rate for Payer: WPS Commercial |
$580.04
|
|
|
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 |
$167.66 |
| Max. Negotiated Rate |
$314.79 |
| Rate for Payer: Aetna Commercial |
$307.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$294.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$181.34
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cigna Commercial |
$314.79
|
| Rate for Payer: Health EOS Commercial |
$304.52
|
| Rate for Payer: HFN Commercial |
$314.79
|
| Rate for Payer: Multiplan Commercial |
$273.73
|
| Rate for Payer: Preferred Network Access Commercial |
$314.79
|
| Rate for Payer: Quartz Beloit One Network |
$167.66
|
| Rate for Payer: Quartz Commercial |
$205.30
|
| Rate for Payer: WEA Trust Commercial |
$188.19
|
| Rate for Payer: WPS Commercial |
$253.43
|
|
|
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 |
$22.43 |
| Max. Negotiated Rate |
$314.79 |
| Rate for Payer: Aetna Commercial |
$307.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$294.26
|
| Rate for Payer: Aetna Managed Medicare |
$95.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$181.34
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cigna Commercial |
$314.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$191.48
|
| Rate for Payer: Health EOS Commercial |
$304.52
|
| Rate for Payer: HFN Commercial |
$314.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$256.62
|
| Rate for Payer: Multiplan Commercial |
$273.73
|
| Rate for Payer: NAPHCARE Commercial |
$205.30
|
| Rate for Payer: Preferred Network Access Commercial |
$314.79
|
| Rate for Payer: Quartz Beloit One Network |
$167.66
|
| Rate for Payer: Quartz Commercial |
$222.40
|
| Rate for Payer: Quartz Medicare Advantage |
$205.30
|
| Rate for Payer: The Alliance Commercial |
$171.08
|
| Rate for Payer: WEA Trust Commercial |
$188.19
|
| Rate for Payer: WPS Commercial |
$253.43
|
|
|
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 |
$22.43 |
| Max. Negotiated Rate |
$2,014.06 |
| Rate for Payer: Aetna Commercial |
$1,970.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,882.71
|
| Rate for Payer: Aetna Managed Medicare |
$612.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,160.28
|
| Rate for Payer: Cash Price |
$631.50
|
| Rate for Payer: Cash Price |
$631.50
|
| Rate for Payer: Cigna Commercial |
$2,014.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,225.11
|
| Rate for Payer: Health EOS Commercial |
$1,948.39
|
| Rate for Payer: HFN Commercial |
$2,014.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,641.90
|
| Rate for Payer: Multiplan Commercial |
$1,751.36
|
| Rate for Payer: NAPHCARE Commercial |
$1,313.52
|
| Rate for Payer: Preferred Network Access Commercial |
$2,014.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,072.71
|
| Rate for Payer: Quartz Commercial |
$1,422.98
|
| Rate for Payer: Quartz Medicare Advantage |
$1,313.52
|
| Rate for Payer: The Alliance Commercial |
$1,094.60
|
| Rate for Payer: WEA Trust Commercial |
$1,204.06
|
| Rate for Payer: WPS Commercial |
$1,621.48
|
|
|
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 |
$1,072.71 |
| Max. Negotiated Rate |
$2,014.06 |
| Rate for Payer: Aetna Commercial |
$1,970.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,882.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,160.28
|
| Rate for Payer: Cash Price |
$631.50
|
| Rate for Payer: Cigna Commercial |
$2,014.06
|
| Rate for Payer: Health EOS Commercial |
$1,948.39
|
| Rate for Payer: HFN Commercial |
$2,014.06
|
| Rate for Payer: Multiplan Commercial |
$1,751.36
|
| Rate for Payer: Preferred Network Access Commercial |
$2,014.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,072.71
|
| Rate for Payer: Quartz Commercial |
$1,313.52
|
| Rate for Payer: WEA Trust Commercial |
$1,204.06
|
| Rate for Payer: WPS Commercial |
$1,621.48
|
|
|
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 |
$22.43 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
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 |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
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 |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
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 |
$22.43 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
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 |
$22.43 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
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 |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
