|
SPLENIC PROCEDURES
|
Facility
|
IP
|
$18,764.18
|
|
|
Service Code
|
APR-DRG 6502
|
| Min. Negotiated Rate |
$16,667.52 |
| Max. Negotiated Rate |
$18,764.18 |
| Rate for Payer: Anthem Medicaid |
$17,967.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$17,967.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17,967.74
|
| Rate for Payer: Dean Health Medicaid |
$17,967.74
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16,667.52
|
| Rate for Payer: Managed Health Services Medicaid |
$18,764.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$17,967.74
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17,967.74
|
| Rate for Payer: United Healthcare Medicaid |
$17,967.74
|
|
|
SPLENIC PROCEDURES
|
Facility
|
IP
|
$37,002.27
|
|
|
Service Code
|
APR-DRG 6504
|
| Min. Negotiated Rate |
$32,867.72 |
| Max. Negotiated Rate |
$37,002.27 |
| Rate for Payer: Anthem Medicaid |
$35,431.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$35,431.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35,431.71
|
| Rate for Payer: Dean Health Medicaid |
$35,431.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$32,867.72
|
| Rate for Payer: Managed Health Services Medicaid |
$37,002.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$35,431.71
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$35,431.71
|
| Rate for Payer: United Healthcare Medicaid |
$35,431.71
|
|
|
SPLENIC PROCEDURES
|
Facility
|
IP
|
$12,889.42
|
|
|
Service Code
|
APR-DRG 6501
|
| Min. Negotiated Rate |
$11,449.18 |
| Max. Negotiated Rate |
$12,889.42 |
| Rate for Payer: Anthem Medicaid |
$12,342.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,342.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,342.33
|
| Rate for Payer: Dean Health Medicaid |
$12,342.33
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,449.18
|
| Rate for Payer: Managed Health Services Medicaid |
$12,889.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,342.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,342.33
|
| Rate for Payer: United Healthcare Medicaid |
$12,342.33
|
|
|
SPLENIC PROCEDURES WITH CC
|
Facility
|
IP
|
$78,241.28
|
|
|
Service Code
|
MSDRG 800
|
| Min. Negotiated Rate |
$22,021.72 |
| Max. Negotiated Rate |
$78,241.28 |
| Rate for Payer: Aetna Managed Medicare |
$22,021.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61,298.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46,985.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44,638.89
|
| Rate for Payer: Anthem Medicare Advantage |
$22,021.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22,021.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22,021.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22,021.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49,553.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22,021.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57,142.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22,021.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22,021.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$22,021.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22,021.72
|
| Rate for Payer: NAPHCARE Commercial |
$33,032.58
|
| Rate for Payer: Quartz Medicare Advantage |
$22,021.72
|
| Rate for Payer: The Alliance Commercial |
$78,241.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22,021.72
|
| Rate for Payer: United Healthcare PPO |
$44,486.52
|
| Rate for Payer: Wellcare Medicare |
$22,021.72
|
|
|
SPLENIC PROCEDURES WITH MCC
|
Facility
|
IP
|
$137,324.72
|
|
|
Service Code
|
MSDRG 799
|
| Min. Negotiated Rate |
$35,189.99 |
| Max. Negotiated Rate |
$137,324.72 |
| Rate for Payer: Aetna Managed Medicare |
$35,189.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98,816.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75,742.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71,960.24
|
| Rate for Payer: Anthem Medicare Advantage |
$35,189.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35,189.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35,189.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35,189.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79,882.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35,189.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100,479.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35,189.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35,189.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35,189.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35,189.99
|
| Rate for Payer: NAPHCARE Commercial |
$52,784.99
|
| Rate for Payer: Quartz Medicare Advantage |
$35,189.99
|
| Rate for Payer: The Alliance Commercial |
$137,324.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35,189.99
|
| Rate for Payer: United Healthcare PPO |
$78,224.41
|
| Rate for Payer: Wellcare Medicare |
$35,189.99
|
|
|
SPLENIC PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$49,817.04
|
|
|
Service Code
|
MSDRG 801
|
| Min. Negotiated Rate |
$15,125.52 |
| Max. Negotiated Rate |
$49,817.04 |
| Rate for Payer: Aetna Managed Medicare |
$15,125.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41,650.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31,924.90
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30,330.74
|
| Rate for Payer: Anthem Medicare Advantage |
$15,125.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,125.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,125.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,125.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33,669.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,125.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36,295.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,125.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,125.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,125.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,125.52
|
| Rate for Payer: NAPHCARE Commercial |
$22,688.28
|
| Rate for Payer: Quartz Medicare Advantage |
$15,125.52
|
| Rate for Payer: The Alliance Commercial |
$49,817.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,125.52
|
| Rate for Payer: United Healthcare PPO |
$28,256.22
|
| Rate for Payer: Wellcare Medicare |
$15,125.52
|
|
|
SPLINT 1 1/4 DIGITAL 11
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2969019
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SPLINT 1 1/4 DIGITAL 11
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2969019
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SPLINT 3 1/4 DIGITAL 13
|
Facility
|
OP
|
$121.00
|
|
| Hospital Charge Code |
2969021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.24 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: The Alliance Commercial |
$62.92
|
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Aetna Managed Medicare |
$35.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.42
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.38
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$75.50
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$81.80
|
| Rate for Payer: Quartz Medicare Advantage |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
SPLINT 3 1/4 DIGITAL 13
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
2969021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
SPLINT 3 1/4 DIGITAL/BULB 15
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2969023
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SPLINT 3 1/4 DIGITAL/BULB 15
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2969023
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SPLINT 4 1/4 DIGITAL 14
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2969022
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SPLINT 4 1/4 DIGITAL 14
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2969022
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SPLINT 4 1/4 DIGITAL/BULB 16
|
Facility
|
OP
|
$134.00
|
|
| Hospital Charge Code |
2969024
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.02 |
| Max. Negotiated Rate |
$128.21 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Aetna Managed Medicare |
$39.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.99
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.52
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: NAPHCARE Commercial |
$83.62
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$90.58
|
| Rate for Payer: Quartz Medicare Advantage |
$83.62
|
| Rate for Payer: The Alliance Commercial |
$69.68
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
SPLINT 4 1/4 DIGITAL/BULB 16
|
Facility
|
IP
|
$134.00
|
|
| Hospital Charge Code |
2969024
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$128.21 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$83.62
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
SPLINT 5 1/4 DIGITAL/BULB 17 9119-07
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2969025
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SPLINT 5 1/4 DIGITAL/BULB 17 9119-07
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2969025
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SPLINT 6 1/4 DIGITAL/BULB 18
|
Facility
|
IP
|
$134.00
|
|
| Hospital Charge Code |
2969026
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$128.21 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$83.62
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
SPLINT 6 1/4 DIGITAL/BULB 18
|
Facility
|
OP
|
$134.00
|
|
| Hospital Charge Code |
2969026
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.02 |
| Max. Negotiated Rate |
$128.21 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Aetna Managed Medicare |
$39.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.99
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.52
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: NAPHCARE Commercial |
$83.62
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$90.58
|
| Rate for Payer: Quartz Medicare Advantage |
$83.62
|
| Rate for Payer: The Alliance Commercial |
$69.68
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
SPLINT 7 1/4 DIGITAL/BULB 9119-09
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2969084
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$31.82
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
SPLINT 7 1/4 DIGITAL/BULB 9119-09
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2969084
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$14.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.68
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.78
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$31.82
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$34.48
|
| Rate for Payer: Quartz Medicare Advantage |
$31.82
|
| Rate for Payer: The Alliance Commercial |
$26.52
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
Splint A4570
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
3133602
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$19.51 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$19.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.99
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.26
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$41.81
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$45.29
|
| Rate for Payer: Quartz Medicare Advantage |
$41.81
|
| Rate for Payer: The Alliance Commercial |
$34.84
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
Splint A4570
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
3133602
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$34.14 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$41.81
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
Splint A4570
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
3133602
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$30.66 |
| Max. Negotiated Rate |
$66.20 |
| Rate for Payer: Aetna Commercial |
$66.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$66.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.81
|
| Rate for Payer: Health EOS Commercial |
$63.41
|
| Rate for Payer: HFN Commercial |
$66.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.22
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$66.20
|
| Rate for Payer: Quartz Beloit One Network |
$30.66
|
| Rate for Payer: Quartz Commercial |
$39.72
|
| Rate for Payer: The Alliance Commercial |
$34.84
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
