|
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
|
|
|
SPLINTS OVAL-8 SZ 5 #9272-85-05
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
2971291
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Aetna Managed Medicare |
$35.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.95
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.75
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$81.25
|
| Rate for Payer: Quartz Medicare Advantage |
$75.00
|
| Rate for Payer: The Alliance Commercial |
$500.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
SPLINTS OVAL-8 SZ 5 #9272-85-05
|
Facility
|
IP
|
$125.00
|
|
| Hospital Charge Code |
2971291
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
SPLINTS OVAL-8 SZ 6 #9272-85-06
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2971292
|
|
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 SZ 6 #9272-85-06
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971292
|
|
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 7 #9272-85-07
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971293
|
|
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 7 #9272-85-07
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2971293
|
|
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 SZ 8 #9272-85-08
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971294
|
|
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 8 #9272-85-08
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2971294
|
|
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 SZ 9 #9272-85-09
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971295
|
|
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 9 #9272-85-09
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2971295
|
|
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
|
|
|
SPLINT SPRING FINGER EXTENSION SZ C #7042-02
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
2970977
|
|
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 SPRING FINGER EXTENSION SZ C #7042-02
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
2970977
|
|
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 TAILOR #A297-00-7
|
Facility
|
OP
|
$813.00
|
|
| Hospital Charge Code |
2971663
|
|
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 TAILOR #A297-00-7
|
Facility
|
IP
|
$813.00
|
|
| Hospital Charge Code |
2971663
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$398.37 |
| Max. Negotiated Rate |
$747.96 |
| Rate for Payer: Aetna Commercial |
$731.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$699.18
|
| 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 TAP LEFT/LARGE #A834-65
|
Facility
|
IP
|
$778.00
|
|
| Hospital Charge Code |
2971627
|
|
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 TAP LEFT/LARGE #A834-65
|
Facility
|
OP
|
$778.00
|
|
| Hospital Charge Code |
2971627
|
|
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 TAP LEFT/MED #A834-63
|
Facility
|
OP
|
$778.00
|
|
| Hospital Charge Code |
2971625
|
|
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 TAP LEFT/MED #A834-63
|
Facility
|
IP
|
$778.00
|
|
| Hospital Charge Code |
2971625
|
|
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 TAP RIGHT/LGE #A834-64
|
Facility
|
IP
|
$778.00
|
|
| Hospital Charge Code |
2971626
|
|
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 TAP RIGHT/LGE #A834-64
|
Facility
|
OP
|
$778.00
|
|
| Hospital Charge Code |
2971626
|
|
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 TAP RIGHT/MED #A834-62
|
Facility
|
OP
|
$778.00
|
|
| Hospital Charge Code |
2971624
|
|
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 TAP RIGHT/MED #A834-62
|
Facility
|
IP
|
$778.00
|
|
| Hospital Charge Code |
2971624
|
|
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 THUMB COMFORT COOL CMC #5506-06-03
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2969671
|
|
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 THUMB COMFORT COOL CMC #5506-06-03
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2969671
|
|
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
|
|
