|
SPLINT OVAL 8 SZ 15 9272-85-15
|
Facility
|
IP
|
$163.00
|
|
| Hospital Charge Code |
3072617
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$79.87 |
| Max. Negotiated Rate |
$149.96 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| 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: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| 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 |
$97.80
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
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
|
|
|
SPLINT ROLYAN TAP LEFT/SMALL
|
Facility
|
IP
|
$764.00
|
|
| Hospital Charge Code |
2971612
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$702.88 |
| Rate for Payer: Aetna Commercial |
$687.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$404.92
|
| Rate for Payer: Cash Price |
$229.20
|
| Rate for Payer: Cigna Commercial |
$702.88
|
| Rate for Payer: Health EOS Commercial |
$679.96
|
| Rate for Payer: HFN Commercial |
$702.88
|
| Rate for Payer: Multiplan Commercial |
$611.20
|
| Rate for Payer: NAPHCARE Commercial |
$458.40
|
| Rate for Payer: Preferred Network Access Commercial |
$702.88
|
| Rate for Payer: Quartz Beloit One Network |
$374.36
|
| Rate for Payer: Quartz Commercial |
$458.40
|
| Rate for Payer: WEA Trust Commercial |
$420.20
|
| Rate for Payer: WPS Commercial |
$565.89
|
|
|
SPLINT ROLYAN TAP LEFT/SMALL
|
Facility
|
OP
|
$764.00
|
|
| Hospital Charge Code |
2971612
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$213.92 |
| Max. Negotiated Rate |
$3,056.00 |
| Rate for Payer: Aetna Commercial |
$687.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.04
|
| Rate for Payer: Aetna Managed Medicare |
$213.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$496.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$382.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$366.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$404.92
|
| Rate for Payer: Cash Price |
$229.20
|
| Rate for Payer: Cigna Commercial |
$702.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$427.53
|
| Rate for Payer: Health EOS Commercial |
$679.96
|
| Rate for Payer: HFN Commercial |
$702.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$573.00
|
| Rate for Payer: Multiplan Commercial |
$611.20
|
| Rate for Payer: NAPHCARE Commercial |
$458.40
|
| Rate for Payer: Preferred Network Access Commercial |
$702.88
|
| Rate for Payer: Quartz Beloit One Network |
$374.36
|
| Rate for Payer: Quartz Commercial |
$496.60
|
| Rate for Payer: Quartz Medicare Advantage |
$458.40
|
| Rate for Payer: The Alliance Commercial |
$3,056.00
|
| Rate for Payer: WEA Trust Commercial |
$420.20
|
| Rate for Payer: WPS Commercial |
$565.89
|
|
|
SPLINT ROLYAN TAP RIGHT/SMALL
|
Facility
|
IP
|
$778.00
|
|
| Hospital Charge Code |
2971611
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$381.22 |
| Max. Negotiated Rate |
$715.76 |
| Rate for Payer: Aetna Commercial |
$700.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$412.34
|
| Rate for Payer: Cash Price |
$233.40
|
| Rate for Payer: Cigna Commercial |
$715.76
|
| Rate for Payer: Health EOS Commercial |
$692.42
|
| Rate for Payer: HFN Commercial |
$715.76
|
| Rate for Payer: Multiplan Commercial |
$622.40
|
| Rate for Payer: NAPHCARE Commercial |
$466.80
|
| Rate for Payer: Preferred Network Access Commercial |
$715.76
|
| Rate for Payer: Quartz Beloit One Network |
$381.22
|
| Rate for Payer: Quartz Commercial |
$466.80
|
| Rate for Payer: WEA Trust Commercial |
$427.90
|
| Rate for Payer: WPS Commercial |
$576.26
|
|
|
SPLINT ROLYAN TAP RIGHT/SMALL
|
Facility
|
OP
|
$778.00
|
|
| Hospital Charge Code |
2971611
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$217.84 |
| Max. Negotiated Rate |
$3,112.00 |
| Rate for Payer: Aetna Commercial |
$700.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.08
|
| Rate for Payer: Aetna Managed Medicare |
$217.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$505.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$389.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$373.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$412.34
|
| Rate for Payer: Cash Price |
$233.40
|
| Rate for Payer: Cigna Commercial |
$715.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$435.37
|
| Rate for Payer: Health EOS Commercial |
$692.42
|
| Rate for Payer: HFN Commercial |
$715.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$583.50
|
| Rate for Payer: Multiplan Commercial |
$622.40
|
| Rate for Payer: NAPHCARE Commercial |
$466.80
|
| Rate for Payer: Preferred Network Access Commercial |
$715.76
|
| Rate for Payer: Quartz Beloit One Network |
$381.22
|
| Rate for Payer: Quartz Commercial |
$505.70
|
| Rate for Payer: Quartz Medicare Advantage |
$466.80
|
| Rate for Payer: The Alliance Commercial |
$3,112.00
|
| Rate for Payer: WEA Trust Commercial |
$427.90
|
| Rate for Payer: WPS Commercial |
$576.26
|
|
|
SPLINT SAM 4 1/4 x18 #928606
|
Facility
|
OP
|
$268.00
|
|
| Hospital Charge Code |
2970852
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$75.04 |
| Max. Negotiated Rate |
$1,072.00 |
| Rate for Payer: Aetna Commercial |
$241.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.48
|
| Rate for Payer: Aetna Managed Medicare |
$75.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$174.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$134.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$128.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.04
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$246.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$149.97
|
| Rate for Payer: Health EOS Commercial |
$238.52
|
| Rate for Payer: HFN Commercial |
$246.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.00
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: NAPHCARE Commercial |
$160.80
|
| Rate for Payer: Preferred Network Access Commercial |
$246.56
|
| Rate for Payer: Quartz Beloit One Network |
$131.32
|
| Rate for Payer: Quartz Commercial |
$174.20
|
| Rate for Payer: Quartz Medicare Advantage |
$160.80
|
| Rate for Payer: The Alliance Commercial |
$1,072.00
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
SPLINT SAM 4 1/4 x18 #928606
|
Facility
|
IP
|
$268.00
|
|
| Hospital Charge Code |
2970852
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$131.32 |
| Max. Negotiated Rate |
$246.56 |
| Rate for Payer: Aetna Commercial |
$241.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.04
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$246.56
|
| Rate for Payer: Health EOS Commercial |
$238.52
|
| Rate for Payer: HFN Commercial |
$246.56
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: NAPHCARE Commercial |
$160.80
|
| Rate for Payer: Preferred Network Access Commercial |
$246.56
|
| Rate for Payer: Quartz Beloit One Network |
$131.32
|
| Rate for Payer: Quartz Commercial |
$160.80
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
SPLINT SAM 4 1/4 x36 #9286-05
|
Facility
|
OP
|
$435.00
|
|
| Hospital Charge Code |
2970320
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$1,740.00 |
| Rate for Payer: Aetna Commercial |
$391.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$374.10
|
| Rate for Payer: Aetna Managed Medicare |
$121.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$282.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$217.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$208.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.55
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$400.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.43
|
| Rate for Payer: Health EOS Commercial |
$387.15
|
| Rate for Payer: HFN Commercial |
$400.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$326.25
|
| Rate for Payer: Multiplan Commercial |
$348.00
|
| Rate for Payer: NAPHCARE Commercial |
$261.00
|
| Rate for Payer: Preferred Network Access Commercial |
$400.20
|
| Rate for Payer: Quartz Beloit One Network |
$213.15
|
| Rate for Payer: Quartz Commercial |
$282.75
|
| Rate for Payer: Quartz Medicare Advantage |
$261.00
|
| Rate for Payer: The Alliance Commercial |
$1,740.00
|
| Rate for Payer: WEA Trust Commercial |
$239.25
|
| Rate for Payer: WPS Commercial |
$322.20
|
|
|
SPLINT SAM 4 1/4 x36 #9286-05
|
Facility
|
IP
|
$435.00
|
|
| Hospital Charge Code |
2970320
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$213.15 |
| Max. Negotiated Rate |
$400.20 |
| Rate for Payer: Aetna Commercial |
$391.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$374.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.55
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$400.20
|
| Rate for Payer: Health EOS Commercial |
$387.15
|
| Rate for Payer: HFN Commercial |
$400.20
|
| Rate for Payer: Multiplan Commercial |
$348.00
|
| Rate for Payer: NAPHCARE Commercial |
$261.00
|
| Rate for Payer: Preferred Network Access Commercial |
$400.20
|
| Rate for Payer: Quartz Beloit One Network |
$213.15
|
| Rate for Payer: Quartz Commercial |
$261.00
|
| Rate for Payer: WEA Trust Commercial |
$239.25
|
| Rate for Payer: WPS Commercial |
$322.20
|
|
|
SPLINT SAM 5 1/2 x36 #5628-77
|
Facility
|
IP
|
$478.00
|
|
| Hospital Charge Code |
2971285
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$234.22 |
| Max. Negotiated Rate |
$439.76 |
| Rate for Payer: Aetna Commercial |
$430.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.34
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$439.76
|
| Rate for Payer: Health EOS Commercial |
$425.42
|
| Rate for Payer: HFN Commercial |
$439.76
|
| Rate for Payer: Multiplan Commercial |
$382.40
|
| Rate for Payer: NAPHCARE Commercial |
$286.80
|
| Rate for Payer: Preferred Network Access Commercial |
$439.76
|
| Rate for Payer: Quartz Beloit One Network |
$234.22
|
| Rate for Payer: Quartz Commercial |
$286.80
|
| Rate for Payer: WEA Trust Commercial |
$262.90
|
| Rate for Payer: WPS Commercial |
$354.05
|
|
|
SPLINT SAM 5 1/2 x36 #5628-77
|
Facility
|
OP
|
$478.00
|
|
| Hospital Charge Code |
2971285
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$133.84 |
| Max. Negotiated Rate |
$1,912.00 |
| Rate for Payer: Aetna Commercial |
$430.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.08
|
| Rate for Payer: Aetna Managed Medicare |
$133.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$310.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.34
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$439.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.49
|
| Rate for Payer: Health EOS Commercial |
$425.42
|
| Rate for Payer: HFN Commercial |
$439.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$358.50
|
| Rate for Payer: Multiplan Commercial |
$382.40
|
| Rate for Payer: NAPHCARE Commercial |
$286.80
|
| Rate for Payer: Preferred Network Access Commercial |
$439.76
|
| Rate for Payer: Quartz Beloit One Network |
$234.22
|
| Rate for Payer: Quartz Commercial |
$310.70
|
| Rate for Payer: Quartz Medicare Advantage |
$286.80
|
| Rate for Payer: The Alliance Commercial |
$1,912.00
|
| Rate for Payer: WEA Trust Commercial |
$262.90
|
| Rate for Payer: WPS Commercial |
$354.05
|
|
|
SPLINTS FINGER (AA) #704101
|
Facility
|
IP
|
$406.00
|
|
| Hospital Charge Code |
2969843
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.94 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$243.60
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
SPLINTS FINGER (AA) #704101
|
Facility
|
OP
|
$406.00
|
|
| Hospital Charge Code |
2969843
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.68 |
| Max. Negotiated Rate |
$1,624.00 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Aetna Managed Medicare |
$113.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$203.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.20
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.50
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$263.90
|
| Rate for Payer: Quartz Medicare Advantage |
$243.60
|
| Rate for Payer: The Alliance Commercial |
$1,624.00
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
Splint, short arm applied - Treatments Done
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 29125
|
| Hospital Charge Code |
3025944
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$115.15 |
| Max. Negotiated Rate |
$216.20 |
| Rate for Payer: Aetna Commercial |
$211.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.55
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$216.20
|
| Rate for Payer: Health EOS Commercial |
$209.15
|
| Rate for Payer: HFN Commercial |
$216.20
|
| Rate for Payer: Multiplan Commercial |
$188.00
|
| Rate for Payer: NAPHCARE Commercial |
$141.00
|
| Rate for Payer: Preferred Network Access Commercial |
$216.20
|
| Rate for Payer: Quartz Beloit One Network |
$115.15
|
| Rate for Payer: Quartz Commercial |
$141.00
|
| Rate for Payer: WEA Trust Commercial |
$129.25
|
| Rate for Payer: WPS Commercial |
$174.06
|
|
|
Splint, short arm applied - Treatments Done
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 29125
|
| Hospital Charge Code |
3025944
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$112.80 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$211.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.10
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$152.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$117.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$112.80
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$216.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$209.15
|
| Rate for Payer: HFN Commercial |
$216.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$188.00
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$216.20
|
| Rate for Payer: Quartz Beloit One Network |
$115.15
|
| Rate for Payer: Quartz Commercial |
$152.75
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$129.25
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$174.06
|
|
|
Splint, short leg applied - Treatments Done
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
CPT 29515
|
| Hospital Charge Code |
3025943
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$155.74 |
| Max. Negotiated Rate |
$4,218.22 |
| 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 |
$622.96
|
| 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, short leg applied - Treatments Done
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
CPT 29515
|
| Hospital Charge Code |
3025943
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$220.99 |
| Max. Negotiated Rate |
$414.92 |
| Rate for Payer: Aetna Commercial |
$405.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$387.86
|
| 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
|
|
|
SPLINTS OVAL - 8 SIZE 11
|
Facility
|
IP
|
$246.00
|
|
| Hospital Charge Code |
2970761
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$120.54 |
| Max. Negotiated Rate |
$226.32 |
| Rate for Payer: Aetna Commercial |
$221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.38
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$226.32
|
| Rate for Payer: Health EOS Commercial |
$218.94
|
| Rate for Payer: HFN Commercial |
$226.32
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: NAPHCARE Commercial |
$147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$226.32
|
| Rate for Payer: Quartz Beloit One Network |
$120.54
|
| Rate for Payer: Quartz Commercial |
$147.60
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
|
SPLINTS OVAL - 8 SIZE 11
|
Facility
|
OP
|
$246.00
|
|
| Hospital Charge Code |
2970761
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.88 |
| Max. Negotiated Rate |
$984.00 |
| Rate for Payer: Aetna Commercial |
$221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.56
|
| Rate for Payer: Aetna Managed Medicare |
$68.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$118.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.38
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$226.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.66
|
| Rate for Payer: Health EOS Commercial |
$218.94
|
| Rate for Payer: HFN Commercial |
$226.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.50
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: NAPHCARE Commercial |
$147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$226.32
|
| Rate for Payer: Quartz Beloit One Network |
$120.54
|
| Rate for Payer: Quartz Commercial |
$159.90
|
| Rate for Payer: Quartz Medicare Advantage |
$147.60
|
| Rate for Payer: The Alliance Commercial |
$984.00
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
|
SPLINTS OVAL - 8 SIZE 12
|
Facility
|
OP
|
$246.00
|
|
| Hospital Charge Code |
2970762
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.88 |
| Max. Negotiated Rate |
$984.00 |
| Rate for Payer: Aetna Commercial |
$221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.56
|
| Rate for Payer: Aetna Managed Medicare |
$68.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$118.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.38
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$226.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.66
|
| Rate for Payer: Health EOS Commercial |
$218.94
|
| Rate for Payer: HFN Commercial |
$226.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.50
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: NAPHCARE Commercial |
$147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$226.32
|
| Rate for Payer: Quartz Beloit One Network |
$120.54
|
| Rate for Payer: Quartz Commercial |
$159.90
|
| Rate for Payer: Quartz Medicare Advantage |
$147.60
|
| Rate for Payer: The Alliance Commercial |
$984.00
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
|
SPLINTS OVAL - 8 SIZE 12
|
Facility
|
IP
|
$246.00
|
|
| Hospital Charge Code |
2970762
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$120.54 |
| Max. Negotiated Rate |
$226.32 |
| Rate for Payer: Aetna Commercial |
$221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.38
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$226.32
|
| Rate for Payer: Health EOS Commercial |
$218.94
|
| Rate for Payer: HFN Commercial |
$226.32
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: NAPHCARE Commercial |
$147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$226.32
|
| Rate for Payer: Quartz Beloit One Network |
$120.54
|
| Rate for Payer: Quartz Commercial |
$147.60
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
|
SPLINTS OVAL-8 SZ10 #9272-85-10
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2971296
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
SPLINTS OVAL-8 SZ10 #9272-85-10
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971296
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$38.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$82.80
|
| Rate for Payer: The Alliance Commercial |
$552.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
SPLINTS OVAL-8 SZ 11 92728511
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
3072554
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| 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 Commercial |
$83.85
|
| 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
|
|
