|
SPLINT COMFORT COOL RT/MED #9272-05-03
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969757
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$1,760.00 |
| Rate for Payer: Aetna Commercial |
$396.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$378.40
|
| Rate for Payer: Aetna Managed Medicare |
$123.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$286.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$220.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$211.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$233.20
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$404.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$246.22
|
| Rate for Payer: Health EOS Commercial |
$391.60
|
| Rate for Payer: HFN Commercial |
$404.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$330.00
|
| Rate for Payer: Multiplan Commercial |
$352.00
|
| Rate for Payer: NAPHCARE Commercial |
$264.00
|
| Rate for Payer: Preferred Network Access Commercial |
$404.80
|
| Rate for Payer: Quartz Beloit One Network |
$215.60
|
| Rate for Payer: Quartz Commercial |
$286.00
|
| Rate for Payer: Quartz Medicare Advantage |
$264.00
|
| Rate for Payer: The Alliance Commercial |
$1,760.00
|
| Rate for Payer: WEA Trust Commercial |
$242.00
|
| Rate for Payer: WPS Commercial |
$325.91
|
|
|
SPLINT COMFORT COOL RT/SM #9272-05-01
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969674
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$1,760.00 |
| Rate for Payer: Aetna Commercial |
$396.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$378.40
|
| Rate for Payer: Aetna Managed Medicare |
$123.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$286.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$220.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$211.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$233.20
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$404.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$246.22
|
| Rate for Payer: Health EOS Commercial |
$391.60
|
| Rate for Payer: HFN Commercial |
$404.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$330.00
|
| Rate for Payer: Multiplan Commercial |
$352.00
|
| Rate for Payer: NAPHCARE Commercial |
$264.00
|
| Rate for Payer: Preferred Network Access Commercial |
$404.80
|
| Rate for Payer: Quartz Beloit One Network |
$215.60
|
| Rate for Payer: Quartz Commercial |
$286.00
|
| Rate for Payer: Quartz Medicare Advantage |
$264.00
|
| Rate for Payer: The Alliance Commercial |
$1,760.00
|
| Rate for Payer: WEA Trust Commercial |
$242.00
|
| Rate for Payer: WPS Commercial |
$325.91
|
|
|
SPLINT COMFORT COOL RT/SM #9272-05-01
|
Facility
|
IP
|
$440.00
|
|
| Hospital Charge Code |
2969674
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$215.60 |
| Max. Negotiated Rate |
$404.80 |
| Rate for Payer: Aetna Commercial |
$396.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$378.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$233.20
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$404.80
|
| Rate for Payer: Health EOS Commercial |
$391.60
|
| Rate for Payer: HFN Commercial |
$404.80
|
| Rate for Payer: Multiplan Commercial |
$352.00
|
| Rate for Payer: NAPHCARE Commercial |
$264.00
|
| Rate for Payer: Preferred Network Access Commercial |
$404.80
|
| Rate for Payer: Quartz Beloit One Network |
$215.60
|
| Rate for Payer: Quartz Commercial |
$264.00
|
| Rate for Payer: WEA Trust Commercial |
$242.00
|
| Rate for Payer: WPS Commercial |
$325.91
|
|
|
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 |
$243.04 |
| Max. Negotiated Rate |
$456.32 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$297.60
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
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 |
$138.88 |
| Max. Negotiated Rate |
$1,984.00 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Aetna Managed Medicare |
$138.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$322.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$248.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$238.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.56
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.00
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$322.40
|
| Rate for Payer: Quartz Medicare Advantage |
$297.60
|
| Rate for Payer: The Alliance Commercial |
$1,984.00
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
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 |
$243.04 |
| Max. Negotiated Rate |
$456.32 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$297.60
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
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 |
$138.88 |
| Max. Negotiated Rate |
$1,984.00 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Aetna Managed Medicare |
$138.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$322.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$248.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$238.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.56
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.00
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$322.40
|
| Rate for Payer: Quartz Medicare Advantage |
$297.60
|
| Rate for Payer: The Alliance Commercial |
$1,984.00
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
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 |
$138.88 |
| Max. Negotiated Rate |
$1,984.00 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Aetna Managed Medicare |
$138.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$322.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$248.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$238.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.56
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.00
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$322.40
|
| Rate for Payer: Quartz Medicare Advantage |
$297.60
|
| Rate for Payer: The Alliance Commercial |
$1,984.00
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
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 |
$243.04 |
| Max. Negotiated Rate |
$456.32 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$297.60
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
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 |
$243.04 |
| Max. Negotiated Rate |
$456.32 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$297.60
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
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 |
$138.88 |
| Max. Negotiated Rate |
$1,984.00 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Aetna Managed Medicare |
$138.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$322.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$248.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$238.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.56
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.00
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$322.40
|
| Rate for Payer: Quartz Medicare Advantage |
$297.60
|
| Rate for Payer: The Alliance Commercial |
$1,984.00
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
SPLINT EXTENSION FINGER A #7053-00"
|
Facility
|
IP
|
$428.00
|
|
| Hospital Charge Code |
2969623
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$209.72 |
| Max. Negotiated Rate |
$393.76 |
| Rate for Payer: Aetna Commercial |
$385.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$368.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.84
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$393.76
|
| Rate for Payer: Health EOS Commercial |
$380.92
|
| Rate for Payer: HFN Commercial |
$393.76
|
| Rate for Payer: Multiplan Commercial |
$342.40
|
| Rate for Payer: NAPHCARE Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$393.76
|
| Rate for Payer: Quartz Beloit One Network |
$209.72
|
| Rate for Payer: Quartz Commercial |
$256.80
|
| Rate for Payer: WEA Trust Commercial |
$235.40
|
| Rate for Payer: WPS Commercial |
$317.02
|
|
|
SPLINT EXTENSION FINGER A #7053-00"
|
Facility
|
OP
|
$428.00
|
|
| Hospital Charge Code |
2969623
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.84 |
| Max. Negotiated Rate |
$1,712.00 |
| Rate for Payer: Aetna Commercial |
$385.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$368.08
|
| Rate for Payer: Aetna Managed Medicare |
$119.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$278.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$214.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$205.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.84
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$393.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$239.51
|
| Rate for Payer: Health EOS Commercial |
$380.92
|
| Rate for Payer: HFN Commercial |
$393.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$321.00
|
| Rate for Payer: Multiplan Commercial |
$342.40
|
| Rate for Payer: NAPHCARE Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$393.76
|
| Rate for Payer: Quartz Beloit One Network |
$209.72
|
| Rate for Payer: Quartz Commercial |
$278.20
|
| Rate for Payer: Quartz Medicare Advantage |
$256.80
|
| Rate for Payer: The Alliance Commercial |
$1,712.00
|
| Rate for Payer: WEA Trust Commercial |
$235.40
|
| Rate for Payer: WPS Commercial |
$317.02
|
|
|
SPLINT EXTENSION FINGER B #7053-01"
|
Facility
|
IP
|
$428.00
|
|
| Hospital Charge Code |
2969624
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$209.72 |
| Max. Negotiated Rate |
$393.76 |
| Rate for Payer: Aetna Commercial |
$385.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$368.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.84
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$393.76
|
| Rate for Payer: Health EOS Commercial |
$380.92
|
| Rate for Payer: HFN Commercial |
$393.76
|
| Rate for Payer: Multiplan Commercial |
$342.40
|
| Rate for Payer: NAPHCARE Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$393.76
|
| Rate for Payer: Quartz Beloit One Network |
$209.72
|
| Rate for Payer: Quartz Commercial |
$256.80
|
| Rate for Payer: WEA Trust Commercial |
$235.40
|
| Rate for Payer: WPS Commercial |
$317.02
|
|
|
SPLINT EXTENSION FINGER B #7053-01"
|
Facility
|
OP
|
$428.00
|
|
| Hospital Charge Code |
2969624
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.84 |
| Max. Negotiated Rate |
$1,712.00 |
| Rate for Payer: Aetna Commercial |
$385.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$368.08
|
| Rate for Payer: Aetna Managed Medicare |
$119.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$278.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$214.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$205.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.84
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$393.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$239.51
|
| Rate for Payer: Health EOS Commercial |
$380.92
|
| Rate for Payer: HFN Commercial |
$393.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$321.00
|
| Rate for Payer: Multiplan Commercial |
$342.40
|
| Rate for Payer: NAPHCARE Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$393.76
|
| Rate for Payer: Quartz Beloit One Network |
$209.72
|
| Rate for Payer: Quartz Commercial |
$278.20
|
| Rate for Payer: Quartz Medicare Advantage |
$256.80
|
| Rate for Payer: The Alliance Commercial |
$1,712.00
|
| Rate for Payer: WEA Trust Commercial |
$235.40
|
| Rate for Payer: WPS Commercial |
$317.02
|
|
|
SPLINT EXTENSION FINGER C #7053-02"
|
Facility
|
IP
|
$428.00
|
|
| Hospital Charge Code |
2969625
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$209.72 |
| Max. Negotiated Rate |
$393.76 |
| Rate for Payer: Aetna Commercial |
$385.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$368.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.84
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$393.76
|
| Rate for Payer: Health EOS Commercial |
$380.92
|
| Rate for Payer: HFN Commercial |
$393.76
|
| Rate for Payer: Multiplan Commercial |
$342.40
|
| Rate for Payer: NAPHCARE Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$393.76
|
| Rate for Payer: Quartz Beloit One Network |
$209.72
|
| Rate for Payer: Quartz Commercial |
$256.80
|
| Rate for Payer: WEA Trust Commercial |
$235.40
|
| Rate for Payer: WPS Commercial |
$317.02
|
|
|
SPLINT EXTENSION FINGER C #7053-02"
|
Facility
|
OP
|
$428.00
|
|
| Hospital Charge Code |
2969625
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.84 |
| Max. Negotiated Rate |
$1,712.00 |
| Rate for Payer: Aetna Commercial |
$385.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$368.08
|
| Rate for Payer: Aetna Managed Medicare |
$119.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$278.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$214.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$205.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.84
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$393.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$239.51
|
| Rate for Payer: Health EOS Commercial |
$380.92
|
| Rate for Payer: HFN Commercial |
$393.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$321.00
|
| Rate for Payer: Multiplan Commercial |
$342.40
|
| Rate for Payer: NAPHCARE Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$393.76
|
| Rate for Payer: Quartz Beloit One Network |
$209.72
|
| Rate for Payer: Quartz Commercial |
$278.20
|
| Rate for Payer: Quartz Medicare Advantage |
$256.80
|
| Rate for Payer: The Alliance Commercial |
$1,712.00
|
| Rate for Payer: WEA Trust Commercial |
$235.40
|
| Rate for Payer: WPS Commercial |
$317.02
|
|
|
SPLINT FINGER EXTENSION #7042-03
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
2970978
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$168.56 |
| Max. Negotiated Rate |
$316.48 |
| Rate for Payer: Aetna Commercial |
$309.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.32
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$316.48
|
| Rate for Payer: Health EOS Commercial |
$306.16
|
| Rate for Payer: HFN Commercial |
$316.48
|
| Rate for Payer: Multiplan Commercial |
$275.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$316.48
|
| Rate for Payer: Quartz Beloit One Network |
$168.56
|
| Rate for Payer: Quartz Commercial |
$206.40
|
| Rate for Payer: WEA Trust Commercial |
$189.20
|
| Rate for Payer: WPS Commercial |
$254.80
|
|
|
SPLINT FINGER EXTENSION #7042-03
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
2970978
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$96.32 |
| Max. Negotiated Rate |
$1,376.00 |
| Rate for Payer: Aetna Commercial |
$309.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.84
|
| Rate for Payer: Aetna Managed Medicare |
$96.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$223.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$172.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$165.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.32
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$316.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.50
|
| Rate for Payer: Health EOS Commercial |
$306.16
|
| Rate for Payer: HFN Commercial |
$316.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.00
|
| Rate for Payer: Multiplan Commercial |
$275.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$316.48
|
| Rate for Payer: Quartz Beloit One Network |
$168.56
|
| Rate for Payer: Quartz Commercial |
$223.60
|
| Rate for Payer: Quartz Medicare Advantage |
$206.40
|
| Rate for Payer: The Alliance Commercial |
$1,376.00
|
| Rate for Payer: WEA Trust Commercial |
$189.20
|
| Rate for Payer: WPS Commercial |
$254.80
|
|
|
SPLINT FINGER EXTENSION AA #7042-04
|
Facility
|
IP
|
$354.00
|
|
| Hospital Charge Code |
2970985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$173.46 |
| Max. Negotiated Rate |
$325.68 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$212.40
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
SPLINT FINGER EXTENSION AA #7042-04
|
Facility
|
OP
|
$354.00
|
|
| Hospital Charge Code |
2970985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Aetna Managed Medicare |
$99.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$230.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$177.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.10
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.50
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$230.10
|
| Rate for Payer: Quartz Medicare Advantage |
$212.40
|
| Rate for Payer: The Alliance Commercial |
$1,416.00
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
SPLINT FINGER EXTENSION A LMB SPRING #7042-00
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
2970975
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$168.56 |
| Max. Negotiated Rate |
$316.48 |
| Rate for Payer: Aetna Commercial |
$309.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.32
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$316.48
|
| Rate for Payer: Health EOS Commercial |
$306.16
|
| Rate for Payer: HFN Commercial |
$316.48
|
| Rate for Payer: Multiplan Commercial |
$275.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$316.48
|
| Rate for Payer: Quartz Beloit One Network |
$168.56
|
| Rate for Payer: Quartz Commercial |
$206.40
|
| Rate for Payer: WEA Trust Commercial |
$189.20
|
| Rate for Payer: WPS Commercial |
$254.80
|
|
|
SPLINT FINGER EXTENSION A LMB SPRING #7042-00
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
2970975
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$96.32 |
| Max. Negotiated Rate |
$1,376.00 |
| Rate for Payer: Aetna Commercial |
$309.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.84
|
| Rate for Payer: Aetna Managed Medicare |
$96.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$223.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$172.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$165.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.32
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$316.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.50
|
| Rate for Payer: Health EOS Commercial |
$306.16
|
| Rate for Payer: HFN Commercial |
$316.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.00
|
| Rate for Payer: Multiplan Commercial |
$275.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$316.48
|
| Rate for Payer: Quartz Beloit One Network |
$168.56
|
| Rate for Payer: Quartz Commercial |
$223.60
|
| Rate for Payer: Quartz Medicare Advantage |
$206.40
|
| Rate for Payer: The Alliance Commercial |
$1,376.00
|
| Rate for Payer: WEA Trust Commercial |
$189.20
|
| Rate for Payer: WPS Commercial |
$254.80
|
|
|
SPLINT FINGER EXTENSION B #7042-01
|
Facility
|
IP
|
$345.00
|
|
| Hospital Charge Code |
2970976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$169.05 |
| Max. Negotiated Rate |
$317.40 |
| Rate for Payer: Aetna Commercial |
$310.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.85
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$317.40
|
| Rate for Payer: Health EOS Commercial |
$307.05
|
| Rate for Payer: HFN Commercial |
$317.40
|
| Rate for Payer: Multiplan Commercial |
$276.00
|
| Rate for Payer: NAPHCARE Commercial |
$207.00
|
| Rate for Payer: Preferred Network Access Commercial |
$317.40
|
| Rate for Payer: Quartz Beloit One Network |
$169.05
|
| Rate for Payer: Quartz Commercial |
$207.00
|
| Rate for Payer: WEA Trust Commercial |
$189.75
|
| Rate for Payer: WPS Commercial |
$255.54
|
|
|
SPLINT FINGER EXTENSION B #7042-01
|
Facility
|
OP
|
$345.00
|
|
| Hospital Charge Code |
2970976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$96.60 |
| Max. Negotiated Rate |
$1,380.00 |
| Rate for Payer: Aetna Commercial |
$310.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.70
|
| Rate for Payer: Aetna Managed Medicare |
$96.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$224.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$172.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.85
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$317.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.06
|
| Rate for Payer: Health EOS Commercial |
$307.05
|
| Rate for Payer: HFN Commercial |
$317.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.75
|
| Rate for Payer: Multiplan Commercial |
$276.00
|
| Rate for Payer: NAPHCARE Commercial |
$207.00
|
| Rate for Payer: Preferred Network Access Commercial |
$317.40
|
| Rate for Payer: Quartz Beloit One Network |
$169.05
|
| Rate for Payer: Quartz Commercial |
$224.25
|
| Rate for Payer: Quartz Medicare Advantage |
$207.00
|
| Rate for Payer: The Alliance Commercial |
$1,380.00
|
| Rate for Payer: WEA Trust Commercial |
$189.75
|
| Rate for Payer: WPS Commercial |
$255.54
|
|
