|
SPLINT FUNCTIONAL POSITION R/M #A311-RM
|
Facility
OP
|
$442.00
|
|
| Hospital Charge Code |
2971144
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$1,768.00 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.12
|
| Rate for Payer: Aetna Managed Medicare |
$123.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$287.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$221.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$212.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.34
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$331.50
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: NAPHCARE Commercial |
$265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$287.30
|
| Rate for Payer: Quartz Medicare Advantage |
$265.20
|
| Rate for Payer: The Alliance Commercial |
$1,768.00
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.39
|
|
|
SPLINT FUNCTIONAL POSITION R/M #A311-RM
|
Facility
IP
|
$442.00
|
|
| Hospital Charge Code |
2971144
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$216.58 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: NAPHCARE Commercial |
$265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$265.20
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.39
|
|
|
SPLINT FUNCTIONAL POSITION R/S #A311-RS
|
Facility
OP
|
$460.00
|
|
| Hospital Charge Code |
2971256
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$1,840.00 |
| Rate for Payer: Aetna Commercial |
$414.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$395.60
|
| Rate for Payer: Aetna Managed Medicare |
$128.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$299.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$220.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.80
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$423.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.42
|
| Rate for Payer: Health EOS Commercial |
$409.40
|
| Rate for Payer: HFN Commercial |
$423.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$345.00
|
| Rate for Payer: Multiplan Commercial |
$368.00
|
| Rate for Payer: NAPHCARE Commercial |
$276.00
|
| Rate for Payer: Preferred Network Access Commercial |
$423.20
|
| Rate for Payer: Quartz Beloit One Network |
$225.40
|
| Rate for Payer: Quartz Commercial |
$299.00
|
| Rate for Payer: Quartz Medicare Advantage |
$276.00
|
| Rate for Payer: The Alliance Commercial |
$1,840.00
|
| Rate for Payer: WEA Trust Commercial |
$253.00
|
| Rate for Payer: WPS Commercial |
$340.72
|
|
|
SPLINT FUNCTIONAL POSITION R/S #A311-RS
|
Facility
IP
|
$460.00
|
|
| Hospital Charge Code |
2971256
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$225.40 |
| Max. Negotiated Rate |
$423.20 |
| Rate for Payer: Aetna Commercial |
$414.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.80
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$423.20
|
| Rate for Payer: Health EOS Commercial |
$409.40
|
| Rate for Payer: HFN Commercial |
$423.20
|
| Rate for Payer: Multiplan Commercial |
$368.00
|
| Rate for Payer: NAPHCARE Commercial |
$276.00
|
| Rate for Payer: Preferred Network Access Commercial |
$423.20
|
| Rate for Payer: Quartz Beloit One Network |
$225.40
|
| Rate for Payer: Quartz Commercial |
$276.00
|
| Rate for Payer: WEA Trust Commercial |
$253.00
|
| Rate for Payer: WPS Commercial |
$340.72
|
|
|
SPLINT HAND FUNCTIONAL POSITION RT/MED #7091-12-01
|
Facility
IP
|
$462.00
|
|
| Hospital Charge Code |
2971170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.38 |
| Max. Negotiated Rate |
$425.04 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.86
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$425.04
|
| Rate for Payer: Health EOS Commercial |
$411.18
|
| Rate for Payer: HFN Commercial |
$425.04
|
| Rate for Payer: Multiplan Commercial |
$369.60
|
| Rate for Payer: NAPHCARE Commercial |
$277.20
|
| Rate for Payer: Preferred Network Access Commercial |
$425.04
|
| Rate for Payer: Quartz Beloit One Network |
$226.38
|
| Rate for Payer: Quartz Commercial |
$277.20
|
| Rate for Payer: WEA Trust Commercial |
$254.10
|
| Rate for Payer: WPS Commercial |
$342.20
|
|
|
SPLINT HAND FUNCTIONAL POSITION RT/MED #7091-12-01
|
Facility
OP
|
$462.00
|
|
| Hospital Charge Code |
2971170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$129.36 |
| Max. Negotiated Rate |
$1,848.00 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.32
|
| Rate for Payer: Aetna Managed Medicare |
$129.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$221.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.86
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$425.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.54
|
| Rate for Payer: Health EOS Commercial |
$411.18
|
| Rate for Payer: HFN Commercial |
$425.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$346.50
|
| Rate for Payer: Multiplan Commercial |
$369.60
|
| Rate for Payer: NAPHCARE Commercial |
$277.20
|
| Rate for Payer: Preferred Network Access Commercial |
$425.04
|
| Rate for Payer: Quartz Beloit One Network |
$226.38
|
| Rate for Payer: Quartz Commercial |
$300.30
|
| Rate for Payer: Quartz Medicare Advantage |
$277.20
|
| Rate for Payer: The Alliance Commercial |
$1,848.00
|
| Rate for Payer: WEA Trust Commercial |
$254.10
|
| Rate for Payer: WPS Commercial |
$342.20
|
|
|
SPLINT LMB FINGER FLEXION D #7046-03
|
Facility
OP
|
$370.00
|
|
| Hospital Charge Code |
2971021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$1,480.00 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Aetna Managed Medicare |
$103.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.05
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.50
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$240.50
|
| Rate for Payer: Quartz Medicare Advantage |
$222.00
|
| Rate for Payer: The Alliance Commercial |
$1,480.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
SPLINT LMB FINGER FLEXION D #7046-03
|
Facility
IP
|
$370.00
|
|
| Hospital Charge Code |
2971021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$340.40 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$222.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
Splint, long arm applied - Treatments Done
|
Facility
OP
|
$451.00
|
|
|
Service Code
|
CPT 29105
|
| Hospital Charge Code |
3025946
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$155.74 |
| Max. Negotiated Rate |
$10,829.40 |
| Rate for Payer: Aetna Commercial |
$405.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$387.86
|
| Rate for Payer: Aetna Managed Medicare |
$155.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$293.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$225.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$216.48
|
| Rate for Payer: Anthem Medicare Advantage |
$155.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$155.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$155.74
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cigna Commercial |
$414.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$155.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$155.74
|
| Rate for Payer: Health EOS Commercial |
$401.39
|
| Rate for Payer: HFN Commercial |
$414.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$579.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$155.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$155.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$155.74
|
| Rate for Payer: Multiplan Commercial |
$360.80
|
| Rate for Payer: NAPHCARE Commercial |
$233.61
|
| Rate for Payer: Preferred Network Access Commercial |
$414.92
|
| Rate for Payer: Quartz Beloit One Network |
$220.99
|
| Rate for Payer: Quartz Commercial |
$293.15
|
| Rate for Payer: Quartz Medicare Advantage |
$155.74
|
| Rate for Payer: The Alliance Commercial |
$10,829.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.74
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$248.05
|
| Rate for Payer: Wellcare Medicare |
$155.74
|
| Rate for Payer: WPS Commercial |
$334.06
|
|
|
Splint, long arm applied - Treatments Done
|
Facility
IP
|
$451.00
|
|
|
Service Code
|
CPT 29105
|
| Hospital Charge Code |
3025946
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$220.99 |
| Max. Negotiated Rate |
$414.92 |
| Rate for Payer: Aetna Commercial |
$405.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.03
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cigna Commercial |
$414.92
|
| Rate for Payer: Health EOS Commercial |
$401.39
|
| Rate for Payer: HFN Commercial |
$414.92
|
| Rate for Payer: Multiplan Commercial |
$360.80
|
| Rate for Payer: NAPHCARE Commercial |
$270.60
|
| Rate for Payer: Preferred Network Access Commercial |
$414.92
|
| Rate for Payer: Quartz Beloit One Network |
$220.99
|
| Rate for Payer: Quartz Commercial |
$270.60
|
| Rate for Payer: WEA Trust Commercial |
$248.05
|
| Rate for Payer: WPS Commercial |
$334.06
|
|
|
Splint, long leg applied - Treatments Done
|
Facility
IP
|
$503.00
|
|
|
Service Code
|
CPT 29505
|
| Hospital Charge Code |
3025945
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$246.47 |
| Max. Negotiated Rate |
$462.76 |
| Rate for Payer: Aetna Commercial |
$452.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$266.59
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna Commercial |
$462.76
|
| Rate for Payer: Health EOS Commercial |
$447.67
|
| Rate for Payer: HFN Commercial |
$462.76
|
| Rate for Payer: Multiplan Commercial |
$402.40
|
| Rate for Payer: NAPHCARE Commercial |
$301.80
|
| Rate for Payer: Preferred Network Access Commercial |
$462.76
|
| Rate for Payer: Quartz Beloit One Network |
$246.47
|
| Rate for Payer: Quartz Commercial |
$301.80
|
| Rate for Payer: WEA Trust Commercial |
$276.65
|
| Rate for Payer: WPS Commercial |
$372.57
|
|
|
Splint, long leg applied - Treatments Done
|
Facility
OP
|
$503.00
|
|
|
Service Code
|
CPT 29505
|
| Hospital Charge Code |
3025945
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$155.74 |
| Max. Negotiated Rate |
$27,265.32 |
| Rate for Payer: Aetna Commercial |
$452.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.58
|
| Rate for Payer: Aetna Managed Medicare |
$155.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$326.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$251.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$241.44
|
| Rate for Payer: Anthem Medicare Advantage |
$155.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$266.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$155.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$155.74
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna Commercial |
$462.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$155.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$155.74
|
| Rate for Payer: Health EOS Commercial |
$447.67
|
| Rate for Payer: HFN Commercial |
$462.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$579.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$155.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$155.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$155.74
|
| Rate for Payer: Multiplan Commercial |
$402.40
|
| Rate for Payer: NAPHCARE Commercial |
$233.61
|
| Rate for Payer: Preferred Network Access Commercial |
$462.76
|
| Rate for Payer: Quartz Beloit One Network |
$246.47
|
| Rate for Payer: Quartz Commercial |
$326.95
|
| Rate for Payer: Quartz Medicare Advantage |
$155.74
|
| Rate for Payer: The Alliance Commercial |
$27,265.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.74
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$276.65
|
| Rate for Payer: Wellcare Medicare |
$155.74
|
| Rate for Payer: WPS Commercial |
$372.57
|
|
|
SPLINT NITE FOOT LG NS2000-14
|
Facility
IP
|
$586.00
|
|
| Hospital Charge Code |
2975028
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$287.14 |
| Max. Negotiated Rate |
$539.12 |
| Rate for Payer: Aetna Commercial |
$527.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$310.58
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$539.12
|
| Rate for Payer: Health EOS Commercial |
$521.54
|
| Rate for Payer: HFN Commercial |
$539.12
|
| Rate for Payer: Multiplan Commercial |
$468.80
|
| Rate for Payer: NAPHCARE Commercial |
$351.60
|
| Rate for Payer: Preferred Network Access Commercial |
$539.12
|
| Rate for Payer: Quartz Beloit One Network |
$287.14
|
| Rate for Payer: Quartz Commercial |
$351.60
|
| Rate for Payer: WEA Trust Commercial |
$322.30
|
| Rate for Payer: WPS Commercial |
$434.05
|
|
|
SPLINT NITE FOOT LG NS2000-14
|
Facility
OP
|
$586.00
|
|
| Hospital Charge Code |
2975028
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$164.08 |
| Max. Negotiated Rate |
$2,344.00 |
| Rate for Payer: Aetna Commercial |
$527.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$503.96
|
| Rate for Payer: Aetna Managed Medicare |
$164.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$380.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$293.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$281.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$310.58
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$539.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$327.93
|
| Rate for Payer: Health EOS Commercial |
$521.54
|
| Rate for Payer: HFN Commercial |
$539.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$439.50
|
| Rate for Payer: Multiplan Commercial |
$468.80
|
| Rate for Payer: NAPHCARE Commercial |
$351.60
|
| Rate for Payer: Preferred Network Access Commercial |
$539.12
|
| Rate for Payer: Quartz Beloit One Network |
$287.14
|
| Rate for Payer: Quartz Commercial |
$380.90
|
| Rate for Payer: Quartz Medicare Advantage |
$351.60
|
| Rate for Payer: The Alliance Commercial |
$2,344.00
|
| Rate for Payer: WEA Trust Commercial |
$322.30
|
| Rate for Payer: WPS Commercial |
$434.05
|
|
|
SPLINT NITE FOOT MED NS2000-12
|
Facility
IP
|
$586.00
|
|
| Hospital Charge Code |
2975027
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$287.14 |
| Max. Negotiated Rate |
$539.12 |
| Rate for Payer: Aetna Commercial |
$527.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$310.58
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$539.12
|
| Rate for Payer: Health EOS Commercial |
$521.54
|
| Rate for Payer: HFN Commercial |
$539.12
|
| Rate for Payer: Multiplan Commercial |
$468.80
|
| Rate for Payer: NAPHCARE Commercial |
$351.60
|
| Rate for Payer: Preferred Network Access Commercial |
$539.12
|
| Rate for Payer: Quartz Beloit One Network |
$287.14
|
| Rate for Payer: Quartz Commercial |
$351.60
|
| Rate for Payer: WEA Trust Commercial |
$322.30
|
| Rate for Payer: WPS Commercial |
$434.05
|
|
|
SPLINT NITE FOOT MED NS2000-12
|
Facility
OP
|
$586.00
|
|
| Hospital Charge Code |
2975027
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$164.08 |
| Max. Negotiated Rate |
$2,344.00 |
| Rate for Payer: Aetna Commercial |
$527.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$503.96
|
| Rate for Payer: Aetna Managed Medicare |
$164.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$380.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$293.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$281.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$310.58
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$539.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$327.93
|
| Rate for Payer: Health EOS Commercial |
$521.54
|
| Rate for Payer: HFN Commercial |
$539.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$439.50
|
| Rate for Payer: Multiplan Commercial |
$468.80
|
| Rate for Payer: NAPHCARE Commercial |
$351.60
|
| Rate for Payer: Preferred Network Access Commercial |
$539.12
|
| Rate for Payer: Quartz Beloit One Network |
$287.14
|
| Rate for Payer: Quartz Commercial |
$380.90
|
| Rate for Payer: Quartz Medicare Advantage |
$351.60
|
| Rate for Payer: The Alliance Commercial |
$2,344.00
|
| Rate for Payer: WEA Trust Commercial |
$322.30
|
| Rate for Payer: WPS Commercial |
$434.05
|
|
|
SPLINT ORTHO GLASS 2 X 15' #OG-2L2"
|
Facility
OP
|
$813.00
|
|
| Hospital Charge Code |
2969540
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$227.64 |
| Max. Negotiated Rate |
$3,252.00 |
| Rate for Payer: Aetna Commercial |
$731.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$699.18
|
| Rate for Payer: Aetna Managed Medicare |
$227.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$528.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$406.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$390.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$430.89
|
| Rate for Payer: Cash Price |
$243.90
|
| Rate for Payer: Cigna Commercial |
$747.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$454.95
|
| Rate for Payer: Health EOS Commercial |
$723.57
|
| Rate for Payer: HFN Commercial |
$747.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$609.75
|
| Rate for Payer: Multiplan Commercial |
$650.40
|
| Rate for Payer: NAPHCARE Commercial |
$487.80
|
| Rate for Payer: Preferred Network Access Commercial |
$747.96
|
| Rate for Payer: Quartz Beloit One Network |
$398.37
|
| Rate for Payer: Quartz Commercial |
$528.45
|
| Rate for Payer: Quartz Medicare Advantage |
$487.80
|
| Rate for Payer: The Alliance Commercial |
$3,252.00
|
| Rate for Payer: WEA Trust Commercial |
$447.15
|
| Rate for Payer: WPS Commercial |
$602.19
|
|
|
SPLINT ORTHO GLASS 2 X 15' #OG-2L2"
|
Facility
IP
|
$813.00
|
|
| Hospital Charge Code |
2969540
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$398.37 |
| Max. Negotiated Rate |
$747.96 |
| Rate for Payer: Aetna Commercial |
$731.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$430.89
|
| Rate for Payer: Cash Price |
$243.90
|
| Rate for Payer: Cigna Commercial |
$747.96
|
| Rate for Payer: Health EOS Commercial |
$723.57
|
| Rate for Payer: HFN Commercial |
$747.96
|
| Rate for Payer: Multiplan Commercial |
$650.40
|
| Rate for Payer: NAPHCARE Commercial |
$487.80
|
| Rate for Payer: Preferred Network Access Commercial |
$747.96
|
| Rate for Payer: Quartz Beloit One Network |
$398.37
|
| Rate for Payer: Quartz Commercial |
$487.80
|
| Rate for Payer: WEA Trust Commercial |
$447.15
|
| Rate for Payer: WPS Commercial |
$602.19
|
|
|
SPLINT ORTHOGLASS 3X12 7344203
|
Facility
OP
|
$139.00
|
|
| Hospital Charge Code |
2974632
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.92 |
| Max. Negotiated Rate |
$556.00 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Aetna Managed Medicare |
$38.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.78
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.25
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$83.40
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$90.35
|
| Rate for Payer: Quartz Medicare Advantage |
$83.40
|
| Rate for Payer: The Alliance Commercial |
$556.00
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
SPLINT ORTHOGLASS 3X12 7344203
|
Facility
IP
|
$139.00
|
|
| Hospital Charge Code |
2974632
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.11 |
| Max. Negotiated Rate |
$127.88 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$83.40
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$83.40
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
SPLINT ORTHO-GLASS COMFORT PRECUT 3 X 35" 73442-00004-00"
|
Facility
IP
|
$389.00
|
|
| Hospital Charge Code |
2972990
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$190.61 |
| Max. Negotiated Rate |
$357.88 |
| Rate for Payer: Aetna Commercial |
$350.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.17
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$357.88
|
| Rate for Payer: Health EOS Commercial |
$346.21
|
| Rate for Payer: HFN Commercial |
$357.88
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: NAPHCARE Commercial |
$233.40
|
| Rate for Payer: Preferred Network Access Commercial |
$357.88
|
| Rate for Payer: Quartz Beloit One Network |
$190.61
|
| Rate for Payer: Quartz Commercial |
$233.40
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
SPLINT ORTHO-GLASS COMFORT PRECUT 3 X 35" 73442-00004-00"
|
Facility
OP
|
$389.00
|
|
| Hospital Charge Code |
2972990
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$108.92 |
| Max. Negotiated Rate |
$1,556.00 |
| Rate for Payer: Aetna Commercial |
$350.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Aetna Managed Medicare |
$108.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$194.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.17
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$357.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.68
|
| Rate for Payer: Health EOS Commercial |
$346.21
|
| Rate for Payer: HFN Commercial |
$357.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$291.75
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: NAPHCARE Commercial |
$233.40
|
| Rate for Payer: Preferred Network Access Commercial |
$357.88
|
| Rate for Payer: Quartz Beloit One Network |
$190.61
|
| Rate for Payer: Quartz Commercial |
$252.85
|
| Rate for Payer: Quartz Medicare Advantage |
$233.40
|
| Rate for Payer: The Alliance Commercial |
$1,556.00
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
SPLINT OVAL 8 SZ 13 9272-85-13
|
Facility
IP
|
$129.00
|
|
| Hospital Charge Code |
3072616
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SPLINT OVAL 8 SZ 13 9272-85-13
|
Facility
OP
|
$129.00
|
|
| Hospital Charge Code |
3072616
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SPLINT OVAL 8 SZ 15 9272-85-15
|
Facility
OP
|
$163.00
|
|
| Hospital Charge Code |
3072617
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.64 |
| Max. Negotiated Rate |
$652.00 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Aetna Managed Medicare |
$45.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.39
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.21
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$122.25
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$97.80
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$105.95
|
| Rate for Payer: Quartz Medicare Advantage |
$97.80
|
| Rate for Payer: The Alliance Commercial |
$652.00
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
