|
SPLINT ANTI SPASTICITY BALL LFT/MED #A419-30-5
|
Facility
|
OP
|
$1,015.00
|
|
| Hospital Charge Code |
2971817
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$295.57 |
| Max. Negotiated Rate |
$971.15 |
| Rate for Payer: Aetna Commercial |
$950.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$907.82
|
| Rate for Payer: Aetna Managed Medicare |
$295.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$686.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$527.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$506.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$559.47
|
| Rate for Payer: Cash Price |
$304.50
|
| Rate for Payer: Cigna Commercial |
$971.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$590.73
|
| Rate for Payer: Health EOS Commercial |
$939.48
|
| Rate for Payer: HFN Commercial |
$971.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$791.70
|
| Rate for Payer: Multiplan Commercial |
$844.48
|
| Rate for Payer: NAPHCARE Commercial |
$633.36
|
| Rate for Payer: Preferred Network Access Commercial |
$971.15
|
| Rate for Payer: Quartz Beloit One Network |
$517.24
|
| Rate for Payer: Quartz Commercial |
$686.14
|
| Rate for Payer: Quartz Medicare Advantage |
$633.36
|
| Rate for Payer: The Alliance Commercial |
$527.80
|
| Rate for Payer: WEA Trust Commercial |
$580.58
|
| Rate for Payer: WPS Commercial |
$781.85
|
|
|
SPLINT ANTI SPASTICITY BALL LFT/MED #A419-30-5
|
Facility
|
IP
|
$1,015.00
|
|
| Hospital Charge Code |
2971817
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$517.24 |
| Max. Negotiated Rate |
$971.15 |
| Rate for Payer: Aetna Commercial |
$950.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$907.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$559.47
|
| Rate for Payer: Cash Price |
$304.50
|
| Rate for Payer: Cigna Commercial |
$971.15
|
| Rate for Payer: Health EOS Commercial |
$939.48
|
| Rate for Payer: HFN Commercial |
$971.15
|
| Rate for Payer: Multiplan Commercial |
$844.48
|
| Rate for Payer: Preferred Network Access Commercial |
$971.15
|
| Rate for Payer: Quartz Beloit One Network |
$517.24
|
| Rate for Payer: Quartz Commercial |
$633.36
|
| Rate for Payer: WEA Trust Commercial |
$580.58
|
| Rate for Payer: WPS Commercial |
$781.85
|
|
|
SPLINT ARM MED 6-17IN LIMB FREEDOM
|
Facility
|
OP
|
$317.00
|
|
| Hospital Charge Code |
2963863
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$303.31 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Aetna Managed Medicare |
$92.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$214.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$164.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.49
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.26
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: NAPHCARE Commercial |
$197.81
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$214.29
|
| Rate for Payer: Quartz Medicare Advantage |
$197.81
|
| Rate for Payer: The Alliance Commercial |
$164.84
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
SPLINT ARM MED 6-17IN LIMB FREEDOM
|
Facility
|
IP
|
$317.00
|
|
| Hospital Charge Code |
2963863
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$161.54 |
| Max. Negotiated Rate |
$303.31 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$197.81
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
SPLINT COMFORT COOL LFT/LRG #9272-05-06
|
Facility
|
IP
|
$440.00
|
|
| Hospital Charge Code |
2969673
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$224.22 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$274.56
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL LFT/LRG #9272-05-06
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969673
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.13 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Aetna Managed Medicare |
$128.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.08
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.20
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: NAPHCARE Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$297.44
|
| Rate for Payer: Quartz Medicare Advantage |
$274.56
|
| Rate for Payer: The Alliance Commercial |
$228.80
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL LFT/SM #9272-05-02
|
Facility
|
IP
|
$440.00
|
|
| Hospital Charge Code |
2969672
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$224.22 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$274.56
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL LFT/SM #9272-05-02
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969672
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.13 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Aetna Managed Medicare |
$128.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.08
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.20
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: NAPHCARE Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$297.44
|
| Rate for Payer: Quartz Medicare Advantage |
$274.56
|
| Rate for Payer: The Alliance Commercial |
$228.80
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL LRG/RT #9272-05-05
|
Facility
|
IP
|
$440.00
|
|
| Hospital Charge Code |
2969657
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$224.22 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$274.56
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL LRG/RT #9272-05-05
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969657
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.13 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Aetna Managed Medicare |
$128.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.08
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.20
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: NAPHCARE Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$297.44
|
| Rate for Payer: Quartz Medicare Advantage |
$274.56
|
| Rate for Payer: The Alliance Commercial |
$228.80
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL MED/LFT #9272-05-04
|
Facility
|
OP
|
$171.00
|
|
| Hospital Charge Code |
2969669
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$49.80 |
| Max. Negotiated Rate |
$163.61 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.94
|
| Rate for Payer: Aetna Managed Medicare |
$49.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$88.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.26
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$163.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.52
|
| Rate for Payer: Health EOS Commercial |
$158.28
|
| Rate for Payer: HFN Commercial |
$163.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.38
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: NAPHCARE Commercial |
$106.70
|
| Rate for Payer: Preferred Network Access Commercial |
$163.61
|
| Rate for Payer: Quartz Beloit One Network |
$87.14
|
| Rate for Payer: Quartz Commercial |
$115.60
|
| Rate for Payer: Quartz Medicare Advantage |
$106.70
|
| Rate for Payer: The Alliance Commercial |
$88.92
|
| Rate for Payer: WEA Trust Commercial |
$97.81
|
| Rate for Payer: WPS Commercial |
$131.72
|
|
|
SPLINT COMFORT COOL MED/LFT #9272-05-04
|
Facility
|
IP
|
$171.00
|
|
| Hospital Charge Code |
2969669
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$87.14 |
| Max. Negotiated Rate |
$163.61 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.26
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$163.61
|
| Rate for Payer: Health EOS Commercial |
$158.28
|
| Rate for Payer: HFN Commercial |
$163.61
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: Preferred Network Access Commercial |
$163.61
|
| Rate for Payer: Quartz Beloit One Network |
$87.14
|
| Rate for Payer: Quartz Commercial |
$106.70
|
| Rate for Payer: WEA Trust Commercial |
$97.81
|
| Rate for Payer: WPS Commercial |
$131.72
|
|
|
SPLINT COMFORT COOL PL LFT/MED #5506-06-04
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2969670
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL PL LFT/MED #5506-06-04
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2969670
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL RT/LRG + #5506-06-05
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2971322
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL RT/LRG + #5506-06-05
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2971322
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL RT/MED #9272-05-03
|
Facility
|
IP
|
$440.00
|
|
| Hospital Charge Code |
2969757
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$224.22 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$274.56
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL RT/MED #9272-05-03
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969757
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.13 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Aetna Managed Medicare |
$128.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.08
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.20
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: NAPHCARE Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$297.44
|
| Rate for Payer: Quartz Medicare Advantage |
$274.56
|
| Rate for Payer: The Alliance Commercial |
$228.80
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL RT/SM #9272-05-01
|
Facility
|
IP
|
$440.00
|
|
| Hospital Charge Code |
2969674
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$224.22 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$274.56
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL RT/SM #9272-05-01
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
2969674
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.13 |
| Max. Negotiated Rate |
$420.99 |
| Rate for Payer: Aetna Commercial |
$411.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.54
|
| Rate for Payer: Aetna Managed Medicare |
$128.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$297.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$219.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.53
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$420.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.08
|
| Rate for Payer: Health EOS Commercial |
$407.26
|
| Rate for Payer: HFN Commercial |
$420.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$343.20
|
| Rate for Payer: Multiplan Commercial |
$366.08
|
| Rate for Payer: NAPHCARE Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$420.99
|
| Rate for Payer: Quartz Beloit One Network |
$224.22
|
| Rate for Payer: Quartz Commercial |
$297.44
|
| Rate for Payer: Quartz Medicare Advantage |
$274.56
|
| Rate for Payer: The Alliance Commercial |
$228.80
|
| Rate for Payer: WEA Trust Commercial |
$251.68
|
| Rate for Payer: WPS Commercial |
$338.93
|
|
|
SPLINT COMFORT COOL THUMB CMC LFT/LRG+ #5506-06-06
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2971324
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC LFT/LRG+ #5506-06-06
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2971324
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC RT/LG + #5506-06-05
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2971323
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC RT/LG + #5506-06-05
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2971323
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
SPLINT COMFORT COOL THUMB CMC RT/SM+ #5506-06-01
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2971320
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
