|
Splint, long arm applied - Treatments Done
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
CPT 29105
|
| Hospital Charge Code |
3025946
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$171.02 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$422.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$403.37
|
| Rate for Payer: Aetna Managed Medicare |
$171.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$304.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$234.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$225.14
|
| Rate for Payer: Anthem Medicare Advantage |
$171.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$171.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$171.02
|
| 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 |
$431.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$171.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$171.02
|
| Rate for Payer: Health EOS Commercial |
$417.45
|
| Rate for Payer: HFN Commercial |
$431.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$636.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$171.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$171.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$171.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$171.02
|
| Rate for Payer: Multiplan Commercial |
$375.23
|
| Rate for Payer: NAPHCARE Commercial |
$256.53
|
| Rate for Payer: Preferred Network Access Commercial |
$431.52
|
| Rate for Payer: Quartz Beloit One Network |
$229.83
|
| Rate for Payer: Quartz Commercial |
$304.88
|
| Rate for Payer: Quartz Medicare Advantage |
$171.02
|
| Rate for Payer: The Alliance Commercial |
$684.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$171.02
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$257.97
|
| Rate for Payer: Wellcare Medicare |
$171.02
|
| Rate for Payer: WPS Commercial |
$347.41
|
|
|
Splint, long leg applied - Treatments Done
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
CPT 29505
|
| Hospital Charge Code |
3025945
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$256.33 |
| Max. Negotiated Rate |
$481.27 |
| Rate for Payer: Aetna Commercial |
$470.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.25
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna Commercial |
$481.27
|
| Rate for Payer: Health EOS Commercial |
$465.58
|
| Rate for Payer: HFN Commercial |
$481.27
|
| Rate for Payer: Multiplan Commercial |
$418.50
|
| Rate for Payer: Preferred Network Access Commercial |
$481.27
|
| Rate for Payer: Quartz Beloit One Network |
$256.33
|
| Rate for Payer: Quartz Commercial |
$313.87
|
| Rate for Payer: WEA Trust Commercial |
$287.72
|
| Rate for Payer: WPS Commercial |
$387.46
|
|
|
Splint, long leg applied - Treatments Done
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
CPT 29505
|
| Hospital Charge Code |
3025945
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$171.02 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$470.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.88
|
| Rate for Payer: Aetna Managed Medicare |
$171.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$340.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$261.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$251.10
|
| Rate for Payer: Anthem Medicare Advantage |
$171.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$171.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$171.02
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna Commercial |
$481.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$171.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$171.02
|
| Rate for Payer: Health EOS Commercial |
$465.58
|
| Rate for Payer: HFN Commercial |
$481.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$636.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$171.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$171.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$171.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$171.02
|
| Rate for Payer: Multiplan Commercial |
$418.50
|
| Rate for Payer: NAPHCARE Commercial |
$256.53
|
| Rate for Payer: Preferred Network Access Commercial |
$481.27
|
| Rate for Payer: Quartz Beloit One Network |
$256.33
|
| Rate for Payer: Quartz Commercial |
$340.03
|
| Rate for Payer: Quartz Medicare Advantage |
$171.02
|
| Rate for Payer: The Alliance Commercial |
$684.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$171.02
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$287.72
|
| Rate for Payer: Wellcare Medicare |
$171.02
|
| Rate for Payer: WPS Commercial |
$387.46
|
|
|
SPLINT NITE FOOT LG NS2000-14
|
Facility
|
OP
|
$586.00
|
|
| Hospital Charge Code |
2975028
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.64 |
| Max. Negotiated Rate |
$560.68 |
| Rate for Payer: Aetna Commercial |
$548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.12
|
| Rate for Payer: Aetna Managed Medicare |
$170.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$396.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$304.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$292.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.00
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$560.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.05
|
| Rate for Payer: Health EOS Commercial |
$542.40
|
| Rate for Payer: HFN Commercial |
$560.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$457.08
|
| Rate for Payer: Multiplan Commercial |
$487.55
|
| Rate for Payer: NAPHCARE Commercial |
$365.66
|
| Rate for Payer: Preferred Network Access Commercial |
$560.68
|
| Rate for Payer: Quartz Beloit One Network |
$298.63
|
| Rate for Payer: Quartz Commercial |
$396.14
|
| Rate for Payer: Quartz Medicare Advantage |
$365.66
|
| Rate for Payer: The Alliance Commercial |
$304.72
|
| Rate for Payer: WEA Trust Commercial |
$335.19
|
| Rate for Payer: WPS Commercial |
$451.40
|
|
|
SPLINT NITE FOOT LG NS2000-14
|
Facility
|
IP
|
$586.00
|
|
| Hospital Charge Code |
2975028
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$298.63 |
| Max. Negotiated Rate |
$560.68 |
| Rate for Payer: Aetna Commercial |
$548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.00
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$560.68
|
| Rate for Payer: Health EOS Commercial |
$542.40
|
| Rate for Payer: HFN Commercial |
$560.68
|
| Rate for Payer: Multiplan Commercial |
$487.55
|
| Rate for Payer: Preferred Network Access Commercial |
$560.68
|
| Rate for Payer: Quartz Beloit One Network |
$298.63
|
| Rate for Payer: Quartz Commercial |
$365.66
|
| Rate for Payer: WEA Trust Commercial |
$335.19
|
| Rate for Payer: WPS Commercial |
$451.40
|
|
|
SPLINT NITE FOOT MED NS2000-12
|
Facility
|
IP
|
$586.00
|
|
| Hospital Charge Code |
2975027
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$298.63 |
| Max. Negotiated Rate |
$560.68 |
| Rate for Payer: Aetna Commercial |
$548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.00
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$560.68
|
| Rate for Payer: Health EOS Commercial |
$542.40
|
| Rate for Payer: HFN Commercial |
$560.68
|
| Rate for Payer: Multiplan Commercial |
$487.55
|
| Rate for Payer: Preferred Network Access Commercial |
$560.68
|
| Rate for Payer: Quartz Beloit One Network |
$298.63
|
| Rate for Payer: Quartz Commercial |
$365.66
|
| Rate for Payer: WEA Trust Commercial |
$335.19
|
| Rate for Payer: WPS Commercial |
$451.40
|
|
|
SPLINT NITE FOOT MED NS2000-12
|
Facility
|
OP
|
$586.00
|
|
| Hospital Charge Code |
2975027
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.64 |
| Max. Negotiated Rate |
$560.68 |
| Rate for Payer: Aetna Commercial |
$548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.12
|
| Rate for Payer: Aetna Managed Medicare |
$170.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$396.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$304.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$292.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.00
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$560.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.05
|
| Rate for Payer: Health EOS Commercial |
$542.40
|
| Rate for Payer: HFN Commercial |
$560.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$457.08
|
| Rate for Payer: Multiplan Commercial |
$487.55
|
| Rate for Payer: NAPHCARE Commercial |
$365.66
|
| Rate for Payer: Preferred Network Access Commercial |
$560.68
|
| Rate for Payer: Quartz Beloit One Network |
$298.63
|
| Rate for Payer: Quartz Commercial |
$396.14
|
| Rate for Payer: Quartz Medicare Advantage |
$365.66
|
| Rate for Payer: The Alliance Commercial |
$304.72
|
| Rate for Payer: WEA Trust Commercial |
$335.19
|
| Rate for Payer: WPS Commercial |
$451.40
|
|
|
SPLINT ORTHO GLASS 2 X 15' #OG-2L2"
|
Facility
|
OP
|
$813.00
|
|
| Hospital Charge Code |
2969540
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$236.75 |
| Max. Negotiated Rate |
$777.88 |
| Rate for Payer: Aetna Commercial |
$760.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$727.15
|
| Rate for Payer: Aetna Managed Medicare |
$236.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$549.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$422.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$405.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$448.13
|
| Rate for Payer: Cash Price |
$243.90
|
| Rate for Payer: Cigna Commercial |
$777.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$473.17
|
| Rate for Payer: Health EOS Commercial |
$752.51
|
| Rate for Payer: HFN Commercial |
$777.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$634.14
|
| Rate for Payer: Multiplan Commercial |
$676.42
|
| Rate for Payer: NAPHCARE Commercial |
$507.31
|
| Rate for Payer: Preferred Network Access Commercial |
$777.88
|
| Rate for Payer: Quartz Beloit One Network |
$414.30
|
| Rate for Payer: Quartz Commercial |
$549.59
|
| Rate for Payer: Quartz Medicare Advantage |
$507.31
|
| Rate for Payer: The Alliance Commercial |
$422.76
|
| Rate for Payer: WEA Trust Commercial |
$465.04
|
| Rate for Payer: WPS Commercial |
$626.25
|
|
|
SPLINT ORTHO GLASS 2 X 15' #OG-2L2"
|
Facility
|
IP
|
$813.00
|
|
| Hospital Charge Code |
2969540
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$414.30 |
| Max. Negotiated Rate |
$777.88 |
| Rate for Payer: Aetna Commercial |
$760.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$727.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$448.13
|
| Rate for Payer: Cash Price |
$243.90
|
| Rate for Payer: Cigna Commercial |
$777.88
|
| Rate for Payer: Health EOS Commercial |
$752.51
|
| Rate for Payer: HFN Commercial |
$777.88
|
| Rate for Payer: Multiplan Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$777.88
|
| Rate for Payer: Quartz Beloit One Network |
$414.30
|
| Rate for Payer: Quartz Commercial |
$507.31
|
| Rate for Payer: WEA Trust Commercial |
$465.04
|
| Rate for Payer: WPS Commercial |
$626.25
|
|
|
SPLINT ORTHOGLASS 3X12 7344203
|
Facility
|
OP
|
$139.00
|
|
| Hospital Charge Code |
2974632
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.48 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$40.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.42
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$86.74
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$86.74
|
| Rate for Payer: The Alliance Commercial |
$72.28
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
SPLINT ORTHOGLASS 3X12 7344203
|
Facility
|
IP
|
$139.00
|
|
| Hospital Charge Code |
2974632
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
SPLINT ORTHO GLASS 3x15' #OG-3L2"
|
Facility
|
IP
|
$966.00
|
|
| Hospital Charge Code |
2969537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$492.27 |
| Max. Negotiated Rate |
$924.27 |
| Rate for Payer: Aetna Commercial |
$904.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$863.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$532.46
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cigna Commercial |
$924.27
|
| Rate for Payer: Health EOS Commercial |
$894.13
|
| Rate for Payer: HFN Commercial |
$924.27
|
| Rate for Payer: Multiplan Commercial |
$803.71
|
| Rate for Payer: Preferred Network Access Commercial |
$924.27
|
| Rate for Payer: Quartz Beloit One Network |
$492.27
|
| Rate for Payer: Quartz Commercial |
$602.78
|
| Rate for Payer: WEA Trust Commercial |
$552.55
|
| Rate for Payer: WPS Commercial |
$744.11
|
|
|
SPLINT ORTHO GLASS 3x15' #OG-3L2"
|
Facility
|
OP
|
$966.00
|
|
| Hospital Charge Code |
2969537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$281.30 |
| Max. Negotiated Rate |
$924.27 |
| Rate for Payer: Aetna Commercial |
$904.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$863.99
|
| Rate for Payer: Aetna Managed Medicare |
$281.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$502.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$532.46
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cigna Commercial |
$924.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.21
|
| Rate for Payer: Health EOS Commercial |
$894.13
|
| Rate for Payer: HFN Commercial |
$924.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$753.48
|
| Rate for Payer: Multiplan Commercial |
$803.71
|
| Rate for Payer: NAPHCARE Commercial |
$602.78
|
| Rate for Payer: Preferred Network Access Commercial |
$924.27
|
| Rate for Payer: Quartz Beloit One Network |
$492.27
|
| Rate for Payer: Quartz Commercial |
$653.02
|
| Rate for Payer: Quartz Medicare Advantage |
$602.78
|
| Rate for Payer: The Alliance Commercial |
$502.32
|
| Rate for Payer: WEA Trust Commercial |
$552.55
|
| Rate for Payer: WPS Commercial |
$744.11
|
|
|
SPLINT ORTHO-GLASS COMFORT PRECUT 3 X 35" 73442-00004-00"
|
Facility
|
OP
|
$389.00
|
|
| Hospital Charge Code |
2972990
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.28 |
| Max. Negotiated Rate |
$372.20 |
| Rate for Payer: Aetna Commercial |
$364.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Aetna Managed Medicare |
$113.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$262.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$202.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.42
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$372.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.40
|
| Rate for Payer: Health EOS Commercial |
$360.06
|
| Rate for Payer: HFN Commercial |
$372.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.42
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: NAPHCARE Commercial |
$242.74
|
| Rate for Payer: Preferred Network Access Commercial |
$372.20
|
| Rate for Payer: Quartz Beloit One Network |
$198.23
|
| Rate for Payer: Quartz Commercial |
$262.96
|
| Rate for Payer: Quartz Medicare Advantage |
$242.74
|
| Rate for Payer: The Alliance Commercial |
$202.28
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: WPS Commercial |
$299.65
|
|
|
SPLINT ORTHO-GLASS COMFORT PRECUT 3 X 35" 73442-00004-00"
|
Facility
|
IP
|
$389.00
|
|
| Hospital Charge Code |
2972990
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.23 |
| Max. Negotiated Rate |
$372.20 |
| Rate for Payer: Aetna Commercial |
$364.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.42
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$372.20
|
| Rate for Payer: Health EOS Commercial |
$360.06
|
| Rate for Payer: HFN Commercial |
$372.20
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: Preferred Network Access Commercial |
$372.20
|
| Rate for Payer: Quartz Beloit One Network |
$198.23
|
| Rate for Payer: Quartz Commercial |
$242.74
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: WPS Commercial |
$299.65
|
|
|
SPLINT OVAL 8 SZ 13 9272-85-13
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
3072616
|
|
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 OVAL 8 SZ 13 9272-85-13
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
3072616
|
|
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 OVAL 8 SZ 15 9272-85-15
|
Facility
|
OP
|
$163.00
|
|
| Hospital Charge Code |
3072617
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.47 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$47.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.87
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.14
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$101.71
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$101.71
|
| Rate for Payer: The Alliance Commercial |
$84.76
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
SPLINT OVAL 8 SZ 15 9272-85-15
|
Facility
|
IP
|
$163.00
|
|
| Hospital Charge Code |
3072617
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
SPLINT ROLYAN TAP LEFT/SMALL
|
Facility
|
OP
|
$764.00
|
|
| Hospital Charge Code |
2971612
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$222.48 |
| Max. Negotiated Rate |
$731.00 |
| Rate for Payer: Aetna Commercial |
$715.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$683.32
|
| Rate for Payer: Aetna Managed Medicare |
$222.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$516.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$397.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$381.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$421.12
|
| Rate for Payer: Cash Price |
$229.20
|
| Rate for Payer: Cigna Commercial |
$731.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$444.65
|
| Rate for Payer: Health EOS Commercial |
$707.16
|
| Rate for Payer: HFN Commercial |
$731.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$595.92
|
| Rate for Payer: Multiplan Commercial |
$635.65
|
| Rate for Payer: NAPHCARE Commercial |
$476.74
|
| Rate for Payer: Preferred Network Access Commercial |
$731.00
|
| Rate for Payer: Quartz Beloit One Network |
$389.33
|
| Rate for Payer: Quartz Commercial |
$516.46
|
| Rate for Payer: Quartz Medicare Advantage |
$476.74
|
| Rate for Payer: The Alliance Commercial |
$397.28
|
| Rate for Payer: WEA Trust Commercial |
$437.01
|
| Rate for Payer: WPS Commercial |
$588.51
|
|
|
SPLINT ROLYAN TAP LEFT/SMALL
|
Facility
|
IP
|
$764.00
|
|
| Hospital Charge Code |
2971612
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$389.33 |
| Max. Negotiated Rate |
$731.00 |
| Rate for Payer: Aetna Commercial |
$715.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$683.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$421.12
|
| Rate for Payer: Cash Price |
$229.20
|
| Rate for Payer: Cigna Commercial |
$731.00
|
| Rate for Payer: Health EOS Commercial |
$707.16
|
| Rate for Payer: HFN Commercial |
$731.00
|
| Rate for Payer: Multiplan Commercial |
$635.65
|
| Rate for Payer: Preferred Network Access Commercial |
$731.00
|
| Rate for Payer: Quartz Beloit One Network |
$389.33
|
| Rate for Payer: Quartz Commercial |
$476.74
|
| Rate for Payer: WEA Trust Commercial |
$437.01
|
| Rate for Payer: WPS Commercial |
$588.51
|
|
|
SPLINT ROLYAN TAP RIGHT/SMALL
|
Facility
|
IP
|
$778.00
|
|
| Hospital Charge Code |
2971611
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$396.47 |
| Max. Negotiated Rate |
$744.39 |
| Rate for Payer: Aetna Commercial |
$728.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$695.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$428.83
|
| Rate for Payer: Cash Price |
$233.40
|
| Rate for Payer: Cigna Commercial |
$744.39
|
| Rate for Payer: Health EOS Commercial |
$720.12
|
| Rate for Payer: HFN Commercial |
$744.39
|
| Rate for Payer: Multiplan Commercial |
$647.30
|
| Rate for Payer: Preferred Network Access Commercial |
$744.39
|
| Rate for Payer: Quartz Beloit One Network |
$396.47
|
| Rate for Payer: Quartz Commercial |
$485.47
|
| Rate for Payer: WEA Trust Commercial |
$445.02
|
| Rate for Payer: WPS Commercial |
$599.29
|
|
|
SPLINT ROLYAN TAP RIGHT/SMALL
|
Facility
|
OP
|
$778.00
|
|
| Hospital Charge Code |
2971611
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.55 |
| Max. Negotiated Rate |
$744.39 |
| Rate for Payer: Aetna Commercial |
$728.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$695.84
|
| Rate for Payer: Aetna Managed Medicare |
$226.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$525.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$404.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$388.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$428.83
|
| Rate for Payer: Cash Price |
$233.40
|
| Rate for Payer: Cigna Commercial |
$744.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$452.80
|
| Rate for Payer: Health EOS Commercial |
$720.12
|
| Rate for Payer: HFN Commercial |
$744.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$606.84
|
| Rate for Payer: Multiplan Commercial |
$647.30
|
| Rate for Payer: NAPHCARE Commercial |
$485.47
|
| Rate for Payer: Preferred Network Access Commercial |
$744.39
|
| Rate for Payer: Quartz Beloit One Network |
$396.47
|
| Rate for Payer: Quartz Commercial |
$525.93
|
| Rate for Payer: Quartz Medicare Advantage |
$485.47
|
| Rate for Payer: The Alliance Commercial |
$404.56
|
| Rate for Payer: WEA Trust Commercial |
$445.02
|
| Rate for Payer: WPS Commercial |
$599.29
|
|
|
SPLINT SAM 4 1/4 x18 #928606
|
Facility
|
IP
|
$268.00
|
|
| Hospital Charge Code |
2970852
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$136.57 |
| Max. Negotiated Rate |
$256.42 |
| Rate for Payer: Aetna Commercial |
$250.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.72
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$256.42
|
| Rate for Payer: Health EOS Commercial |
$248.06
|
| Rate for Payer: HFN Commercial |
$256.42
|
| Rate for Payer: Multiplan Commercial |
$222.98
|
| Rate for Payer: Preferred Network Access Commercial |
$256.42
|
| Rate for Payer: Quartz Beloit One Network |
$136.57
|
| Rate for Payer: Quartz Commercial |
$167.23
|
| Rate for Payer: WEA Trust Commercial |
$153.30
|
| Rate for Payer: WPS Commercial |
$206.44
|
|
|
SPLINT SAM 4 1/4 x18 #928606
|
Facility
|
OP
|
$268.00
|
|
| Hospital Charge Code |
2970852
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$78.04 |
| Max. Negotiated Rate |
$256.42 |
| Rate for Payer: Aetna Commercial |
$250.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.70
|
| Rate for Payer: Aetna Managed Medicare |
$78.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$181.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$139.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$133.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.72
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$256.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.98
|
| Rate for Payer: Health EOS Commercial |
$248.06
|
| Rate for Payer: HFN Commercial |
$256.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.04
|
| Rate for Payer: Multiplan Commercial |
$222.98
|
| Rate for Payer: NAPHCARE Commercial |
$167.23
|
| Rate for Payer: Preferred Network Access Commercial |
$256.42
|
| Rate for Payer: Quartz Beloit One Network |
$136.57
|
| Rate for Payer: Quartz Commercial |
$181.17
|
| Rate for Payer: Quartz Medicare Advantage |
$167.23
|
| Rate for Payer: The Alliance Commercial |
$139.36
|
| Rate for Payer: WEA Trust Commercial |
$153.30
|
| Rate for Payer: WPS Commercial |
$206.44
|
|
