|
Forearm/arm cuffs free motio L3720
|
Professional
|
Both
|
$2,375.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
4253642
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,045.00 |
| Max. Negotiated Rate |
$2,256.25 |
| Rate for Payer: Aetna Commercial |
$2,256.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,042.50
|
| Rate for Payer: Cash Price |
$712.50
|
| Rate for Payer: Cash Price |
$712.50
|
| Rate for Payer: Cigna Commercial |
$2,256.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,187.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,425.00
|
| Rate for Payer: Health EOS Commercial |
$2,161.25
|
| Rate for Payer: HFN Commercial |
$2,256.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,203.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,203.50
|
| Rate for Payer: Multiplan Commercial |
$1,900.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,256.25
|
| Rate for Payer: Quartz Beloit One Network |
$1,045.00
|
| Rate for Payer: Quartz Commercial |
$1,353.75
|
| Rate for Payer: The Alliance Commercial |
$1,187.50
|
| Rate for Payer: WEA Trust Commercial |
$1,306.25
|
| Rate for Payer: WPS Commercial |
$1,759.16
|
|
|
Forearm/arm cuffs free motio L3720
|
Facility
|
OP
|
$2,375.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
4253642
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$289.97 |
| Max. Negotiated Rate |
$9,500.00 |
| Rate for Payer: Aetna Commercial |
$2,137.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,042.50
|
| Rate for Payer: Aetna Managed Medicare |
$665.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$289.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$289.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$289.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,258.75
|
| Rate for Payer: Cash Price |
$712.50
|
| Rate for Payer: Cash Price |
$712.50
|
| Rate for Payer: Cigna Commercial |
$2,185.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,329.05
|
| Rate for Payer: Health EOS Commercial |
$2,113.75
|
| Rate for Payer: HFN Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,781.25
|
| Rate for Payer: Multiplan Commercial |
$1,900.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,425.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,185.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,163.75
|
| Rate for Payer: Quartz Commercial |
$1,543.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,425.00
|
| Rate for Payer: The Alliance Commercial |
$9,500.00
|
| Rate for Payer: WEA Trust Commercial |
$1,306.25
|
| Rate for Payer: WPS Commercial |
$1,759.16
|
|
|
Forearm/arm cuffs free motio L3720
|
Facility
|
IP
|
$2,375.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
4253642
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,163.75 |
| Max. Negotiated Rate |
$2,185.00 |
| Rate for Payer: Aetna Commercial |
$2,137.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,042.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,258.75
|
| Rate for Payer: Cash Price |
$712.50
|
| Rate for Payer: Cigna Commercial |
$2,185.00
|
| Rate for Payer: Health EOS Commercial |
$2,113.75
|
| Rate for Payer: HFN Commercial |
$2,185.00
|
| Rate for Payer: Multiplan Commercial |
$1,900.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,425.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,185.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,163.75
|
| Rate for Payer: Quartz Commercial |
$1,425.00
|
| Rate for Payer: WEA Trust Commercial |
$1,306.25
|
| Rate for Payer: WPS Commercial |
$1,759.16
|
|
|
Forearm Based Cock up Custom
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
HCPCS L3906
|
| Hospital Charge Code |
2989893
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$140.14 |
| Max. Negotiated Rate |
$263.12 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Forearm Based Cock up Custom
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS L3906
|
| Hospital Charge Code |
2989893
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$1,144.00 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Aetna Managed Medicare |
$80.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$237.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$237.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$237.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.05
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$214.50
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$185.90
|
| Rate for Payer: Quartz Medicare Advantage |
$171.60
|
| Rate for Payer: The Alliance Commercial |
$1,144.00
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Fore Arm Based Thumb Spica Custom
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS L3906
|
| Hospital Charge Code |
2989894
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$1,144.00 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Aetna Managed Medicare |
$80.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$237.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$237.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$237.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.05
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$214.50
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$185.90
|
| Rate for Payer: Quartz Medicare Advantage |
$171.60
|
| Rate for Payer: The Alliance Commercial |
$1,144.00
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Fore Arm Based Thumb Spica Custom
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
HCPCS L3906
|
| Hospital Charge Code |
2989894
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$140.14 |
| Max. Negotiated Rate |
$263.12 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
FOREARM BONE GRAFTING
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2959861
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FOREARM BONE GRAFTING
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2959861
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FOREARM OSTEOTOMY
|
Facility
|
IP
|
$4,560.00
|
|
| Hospital Charge Code |
2960288
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,234.40 |
| Max. Negotiated Rate |
$4,195.20 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
FOREARM OSTEOTOMY
|
Facility
|
OP
|
$4,560.00
|
|
| Hospital Charge Code |
2960288
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,276.80 |
| Max. Negotiated Rate |
$18,240.00 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,276.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,964.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,280.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,188.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,551.78
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,420.00
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,736.00
|
| Rate for Payer: The Alliance Commercial |
$18,240.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
FOREARM, TENDON & NERVE REPAIR
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2960420
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FOREARM, TENDON & NERVE REPAIR
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2960420
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FOREFOOT SOCK SZ MED 64958/NA/MD
|
Facility
|
IP
|
$360.00
|
|
| Hospital Charge Code |
3072623
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
FOREFOOT SOCK SZ MED 64958/NA/MD
|
Facility
|
OP
|
$360.00
|
|
| Hospital Charge Code |
3072623
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Aetna Managed Medicare |
$100.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$234.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$180.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$172.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$201.46
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$270.00
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: Quartz Medicare Advantage |
$216.00
|
| Rate for Payer: The Alliance Commercial |
$1,440.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
FOREFOOT SOCK SZ SM 64958/NA/SM
|
Facility
|
IP
|
$360.00
|
|
| Hospital Charge Code |
3072622
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
FOREFOOT SOCK SZ SM 64958/NA/SM
|
Facility
|
OP
|
$360.00
|
|
| Hospital Charge Code |
3072622
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Aetna Managed Medicare |
$100.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$234.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$180.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$172.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$201.46
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$270.00
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: Quartz Medicare Advantage |
$216.00
|
| Rate for Payer: The Alliance Commercial |
$1,440.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL PATTERN FLAP, PARAMEDIAN FOREHEAD FLAP)
|
Facility
|
OP
|
$14,184.12
|
|
|
Service Code
|
CPT 15731
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,546.03 |
| Max. Negotiated Rate |
$14,184.12 |
| Rate for Payer: Aetna Managed Medicare |
$3,546.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,546.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,546.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,546.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,546.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,546.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,191.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,546.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,546.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,546.03
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,546.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,319.04
|
| Rate for Payer: Quartz Medicare Advantage |
$3,546.03
|
| Rate for Payer: The Alliance Commercial |
$14,184.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,546.03
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,546.03
|
|
|
Foreign body - Bronchoscopy Charge
|
Facility
|
OP
|
$7,660.00
|
|
|
Service Code
|
CPT 31635
|
| Hospital Charge Code |
2990188
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$1,677.59 |
| Max. Negotiated Rate |
$7,047.20 |
| Rate for Payer: Aetna Commercial |
$6,894.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,587.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,677.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,979.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,830.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,676.80
|
| Rate for Payer: Anthem Medicare Advantage |
$1,677.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,059.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,677.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,677.59
|
| Rate for Payer: Cash Price |
$2,298.00
|
| Rate for Payer: Cash Price |
$2,298.00
|
| Rate for Payer: Cigna Commercial |
$7,047.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,677.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,677.59
|
| Rate for Payer: Health EOS Commercial |
$6,817.40
|
| Rate for Payer: HFN Commercial |
$7,047.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,240.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,677.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,677.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,677.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,677.59
|
| Rate for Payer: Multiplan Commercial |
$6,128.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,516.38
|
| Rate for Payer: Preferred Network Access Commercial |
$7,047.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,753.40
|
| Rate for Payer: Quartz Commercial |
$4,979.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,677.59
|
| Rate for Payer: The Alliance Commercial |
$2,851.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,677.59
|
| Rate for Payer: United Healthcare PPO |
$5,745.00
|
| Rate for Payer: WEA Trust Commercial |
$4,213.00
|
| Rate for Payer: Wellcare Medicare |
$1,677.59
|
| Rate for Payer: WPS Commercial |
$5,673.76
|
|
|
Foreign body - Bronchoscopy Charge
|
Facility
|
IP
|
$7,660.00
|
|
|
Service Code
|
CPT 31635
|
| Hospital Charge Code |
2990188
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$3,753.40 |
| Max. Negotiated Rate |
$7,047.20 |
| Rate for Payer: Aetna Commercial |
$6,894.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,587.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,059.80
|
| Rate for Payer: Cash Price |
$2,298.00
|
| Rate for Payer: Cigna Commercial |
$7,047.20
|
| Rate for Payer: Health EOS Commercial |
$6,817.40
|
| Rate for Payer: HFN Commercial |
$7,047.20
|
| Rate for Payer: Multiplan Commercial |
$6,128.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,596.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,047.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,753.40
|
| Rate for Payer: Quartz Commercial |
$4,596.00
|
| Rate for Payer: WEA Trust Commercial |
$4,213.00
|
| Rate for Payer: WPS Commercial |
$5,673.76
|
|
|
FOREIGN BODY REMOVAL, ANUS
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960057
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
FOREIGN BODY REMOVAL, ANUS
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960057
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
FOREIGN BODY REMOVAL, EAR
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960058
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
FOREIGN BODY REMOVAL, EAR
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960058
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
FOREIGN BODY REMOVAL, EYE
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960059
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
