|
SPLINT COMFORT COOL RT/LRG + #5506-06-05
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2971322
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL RT/MED #9272-05-03
|
Facility
|
IP
|
$440.00
|
|
| Hospital Charge Code |
2969757
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$224.22 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$274.56
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL RT/MED #9272-05-03
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969757
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.13 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Aetna Managed Medicare |
$128.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.08
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.20
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: NAPHCARE Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$297.44
|
| Rate for Payer: Quartz Medicare Advantage |
$274.56
|
| Rate for Payer: The Alliance Commercial |
$228.80
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL RT/SM #9272-05-01
|
Facility
|
IP
|
$440.00
|
|
| Hospital Charge Code |
2969674
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$224.22 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$274.56
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL RT/SM #9272-05-01
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969674
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.13 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Aetna Managed Medicare |
$128.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.08
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.20
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: NAPHCARE Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$297.44
|
| Rate for Payer: Quartz Medicare Advantage |
$274.56
|
| Rate for Payer: The Alliance Commercial |
$228.80
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL THUMB CMC LFT/LRG+ #5506-06-06
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2971324
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC LFT/LRG+ #5506-06-06
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2971324
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC RT/LG + #5506-06-05
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2971323
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC RT/LG + #5506-06-05
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2971323
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC RT/SM+ #5506-06-01
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2971320
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC RT/SM+ #5506-06-01
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2971320
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC S+/ LFT #5506-06-02
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2971321
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC S+/ LFT #5506-06-02
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2971321
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT EXTENSION FINGER A #7053-00"
|
Facility
|
OP
|
$428.00
|
|
| Hospital Charge Code |
2969623
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$409.51 |
| Rate for Payer: Aetna Commercial |
$400.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.80
|
| Rate for Payer: Aetna Managed Medicare |
$124.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$289.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$222.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$213.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.91
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$409.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.10
|
| Rate for Payer: Health EOS Commercial |
$396.16
|
| Rate for Payer: HFN Commercial |
$409.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.84
|
| Rate for Payer: Multiplan Commercial |
$356.10
|
| Rate for Payer: NAPHCARE Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$409.51
|
| Rate for Payer: Quartz Beloit One Network |
$218.11
|
| Rate for Payer: Quartz Commercial |
$289.33
|
| Rate for Payer: Quartz Medicare Advantage |
$267.07
|
| Rate for Payer: The Alliance Commercial |
$222.56
|
| Rate for Payer: WEA Trust Commercial |
$244.82
|
| Rate for Payer: WPS Commercial |
$329.69
|
|
|
SPLINT EXTENSION FINGER A #7053-00"
|
Facility
|
IP
|
$428.00
|
|
| Hospital Charge Code |
2969623
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$218.11 |
| Max. Negotiated Rate |
$409.51 |
| Rate for Payer: Aetna Commercial |
$400.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.91
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$409.51
|
| Rate for Payer: Health EOS Commercial |
$396.16
|
| Rate for Payer: HFN Commercial |
$409.51
|
| Rate for Payer: Multiplan Commercial |
$356.10
|
| Rate for Payer: Preferred Network Access Commercial |
$409.51
|
| Rate for Payer: Quartz Beloit One Network |
$218.11
|
| Rate for Payer: Quartz Commercial |
$267.07
|
| Rate for Payer: WEA Trust Commercial |
$244.82
|
| Rate for Payer: WPS Commercial |
$329.69
|
|
|
SPLINT EXTENSION FINGER B #7053-01"
|
Facility
|
OP
|
$428.00
|
|
| Hospital Charge Code |
2969624
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$409.51 |
| Rate for Payer: Aetna Commercial |
$400.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.80
|
| Rate for Payer: Aetna Managed Medicare |
$124.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$289.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$222.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$213.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.91
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$409.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.10
|
| Rate for Payer: Health EOS Commercial |
$396.16
|
| Rate for Payer: HFN Commercial |
$409.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.84
|
| Rate for Payer: Multiplan Commercial |
$356.10
|
| Rate for Payer: NAPHCARE Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$409.51
|
| Rate for Payer: Quartz Beloit One Network |
$218.11
|
| Rate for Payer: Quartz Commercial |
$289.33
|
| Rate for Payer: Quartz Medicare Advantage |
$267.07
|
| Rate for Payer: The Alliance Commercial |
$222.56
|
| Rate for Payer: WEA Trust Commercial |
$244.82
|
| Rate for Payer: WPS Commercial |
$329.69
|
|
|
SPLINT EXTENSION FINGER B #7053-01"
|
Facility
|
IP
|
$428.00
|
|
| Hospital Charge Code |
2969624
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$218.11 |
| Max. Negotiated Rate |
$409.51 |
| Rate for Payer: Aetna Commercial |
$400.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.91
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$409.51
|
| Rate for Payer: Health EOS Commercial |
$396.16
|
| Rate for Payer: HFN Commercial |
$409.51
|
| Rate for Payer: Multiplan Commercial |
$356.10
|
| Rate for Payer: Preferred Network Access Commercial |
$409.51
|
| Rate for Payer: Quartz Beloit One Network |
$218.11
|
| Rate for Payer: Quartz Commercial |
$267.07
|
| Rate for Payer: WEA Trust Commercial |
$244.82
|
| Rate for Payer: WPS Commercial |
$329.69
|
|
|
SPLINT EXTENSION FINGER C #7053-02"
|
Facility
|
IP
|
$428.00
|
|
| Hospital Charge Code |
2969625
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$218.11 |
| Max. Negotiated Rate |
$409.51 |
| Rate for Payer: Aetna Commercial |
$400.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.91
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$409.51
|
| Rate for Payer: Health EOS Commercial |
$396.16
|
| Rate for Payer: HFN Commercial |
$409.51
|
| Rate for Payer: Multiplan Commercial |
$356.10
|
| Rate for Payer: Preferred Network Access Commercial |
$409.51
|
| Rate for Payer: Quartz Beloit One Network |
$218.11
|
| Rate for Payer: Quartz Commercial |
$267.07
|
| Rate for Payer: WEA Trust Commercial |
$244.82
|
| Rate for Payer: WPS Commercial |
$329.69
|
|
|
SPLINT EXTENSION FINGER C #7053-02"
|
Facility
|
OP
|
$428.00
|
|
| Hospital Charge Code |
2969625
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$409.51 |
| Rate for Payer: Aetna Commercial |
$400.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.80
|
| Rate for Payer: Aetna Managed Medicare |
$124.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$289.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$222.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$213.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.91
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$409.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.10
|
| Rate for Payer: Health EOS Commercial |
$396.16
|
| Rate for Payer: HFN Commercial |
$409.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.84
|
| Rate for Payer: Multiplan Commercial |
$356.10
|
| Rate for Payer: NAPHCARE Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$409.51
|
| Rate for Payer: Quartz Beloit One Network |
$218.11
|
| Rate for Payer: Quartz Commercial |
$289.33
|
| Rate for Payer: Quartz Medicare Advantage |
$267.07
|
| Rate for Payer: The Alliance Commercial |
$222.56
|
| Rate for Payer: WEA Trust Commercial |
$244.82
|
| Rate for Payer: WPS Commercial |
$329.69
|
|
|
SPLINT FINGER EXTENSION #7042-03
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
2970978
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$175.30 |
| Max. Negotiated Rate |
$329.14 |
| Rate for Payer: Aetna Commercial |
$321.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.61
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$329.14
|
| Rate for Payer: Health EOS Commercial |
$318.41
|
| Rate for Payer: HFN Commercial |
$329.14
|
| Rate for Payer: Multiplan Commercial |
$286.21
|
| Rate for Payer: Preferred Network Access Commercial |
$329.14
|
| Rate for Payer: Quartz Beloit One Network |
$175.30
|
| Rate for Payer: Quartz Commercial |
$214.66
|
| Rate for Payer: WEA Trust Commercial |
$196.77
|
| Rate for Payer: WPS Commercial |
$264.98
|
|
|
SPLINT FINGER EXTENSION #7042-03
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
2970978
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$100.17 |
| Max. Negotiated Rate |
$329.14 |
| Rate for Payer: Aetna Commercial |
$321.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.67
|
| Rate for Payer: Aetna Managed Medicare |
$100.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$232.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$178.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.61
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$329.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.21
|
| Rate for Payer: Health EOS Commercial |
$318.41
|
| Rate for Payer: HFN Commercial |
$329.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.32
|
| Rate for Payer: Multiplan Commercial |
$286.21
|
| Rate for Payer: NAPHCARE Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$329.14
|
| Rate for Payer: Quartz Beloit One Network |
$175.30
|
| Rate for Payer: Quartz Commercial |
$232.54
|
| Rate for Payer: Quartz Medicare Advantage |
$214.66
|
| Rate for Payer: The Alliance Commercial |
$178.88
|
| Rate for Payer: WEA Trust Commercial |
$196.77
|
| Rate for Payer: WPS Commercial |
$264.98
|
|
|
SPLINT FINGER EXTENSION AA #7042-04
|
Facility
|
IP
|
$354.00
|
|
| Hospital Charge Code |
2970985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
SPLINT FINGER EXTENSION AA #7042-04
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2970985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$103.08 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.03
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$184.08
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
SPLINT FINGER EXTENSION A LMB SPRING #7042-00
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
2970975
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$175.30 |
| Max. Negotiated Rate |
$329.14 |
| Rate for Payer: Aetna Commercial |
$321.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.61
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$329.14
|
| Rate for Payer: Health EOS Commercial |
$318.41
|
| Rate for Payer: HFN Commercial |
$329.14
|
| Rate for Payer: Multiplan Commercial |
$286.21
|
| Rate for Payer: Preferred Network Access Commercial |
$329.14
|
| Rate for Payer: Quartz Beloit One Network |
$175.30
|
| Rate for Payer: Quartz Commercial |
$214.66
|
| Rate for Payer: WEA Trust Commercial |
$196.77
|
| Rate for Payer: WPS Commercial |
$264.98
|
|
|
SPLINT FINGER EXTENSION A LMB SPRING #7042-00
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
2970975
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$100.17 |
| Max. Negotiated Rate |
$329.14 |
| Rate for Payer: Aetna Commercial |
$321.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.67
|
| Rate for Payer: Aetna Managed Medicare |
$100.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$232.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$178.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.61
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$329.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.21
|
| Rate for Payer: Health EOS Commercial |
$318.41
|
| Rate for Payer: HFN Commercial |
$329.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.32
|
| Rate for Payer: Multiplan Commercial |
$286.21
|
| Rate for Payer: NAPHCARE Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$329.14
|
| Rate for Payer: Quartz Beloit One Network |
$175.30
|
| Rate for Payer: Quartz Commercial |
$232.54
|
| Rate for Payer: Quartz Medicare Advantage |
$214.66
|
| Rate for Payer: The Alliance Commercial |
$178.88
|
| Rate for Payer: WEA Trust Commercial |
$196.77
|
| Rate for Payer: WPS Commercial |
$264.98
|
|
