|
SPLINT SAM 4 1/4 x36 #9286-05
|
Facility
|
IP
|
$435.00
|
|
| Hospital Charge Code |
2970320
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$221.68 |
| Max. Negotiated Rate |
$416.21 |
| Rate for Payer: Aetna Commercial |
$407.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$389.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.77
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$416.21
|
| Rate for Payer: Health EOS Commercial |
$402.64
|
| Rate for Payer: HFN Commercial |
$416.21
|
| Rate for Payer: Multiplan Commercial |
$361.92
|
| Rate for Payer: Preferred Network Access Commercial |
$416.21
|
| Rate for Payer: Quartz Beloit One Network |
$221.68
|
| Rate for Payer: Quartz Commercial |
$271.44
|
| Rate for Payer: WEA Trust Commercial |
$248.82
|
| Rate for Payer: WPS Commercial |
$335.08
|
|
|
SPLINT SAM 4 1/4 x36 #9286-05
|
Facility
|
OP
|
$435.00
|
|
| Hospital Charge Code |
2970320
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$126.67 |
| Max. Negotiated Rate |
$416.21 |
| Rate for Payer: Aetna Commercial |
$407.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$389.06
|
| Rate for Payer: Aetna Managed Medicare |
$126.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$294.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$226.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$217.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.77
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$416.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$253.17
|
| Rate for Payer: Health EOS Commercial |
$402.64
|
| Rate for Payer: HFN Commercial |
$416.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$339.30
|
| Rate for Payer: Multiplan Commercial |
$361.92
|
| Rate for Payer: NAPHCARE Commercial |
$271.44
|
| Rate for Payer: Preferred Network Access Commercial |
$416.21
|
| Rate for Payer: Quartz Beloit One Network |
$221.68
|
| Rate for Payer: Quartz Commercial |
$294.06
|
| Rate for Payer: Quartz Medicare Advantage |
$271.44
|
| Rate for Payer: The Alliance Commercial |
$226.20
|
| Rate for Payer: WEA Trust Commercial |
$248.82
|
| Rate for Payer: WPS Commercial |
$335.08
|
|
|
SPLINT SAM 5 1/2 x36 #5628-77
|
Facility
|
OP
|
$478.00
|
|
| Hospital Charge Code |
2971285
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$139.19 |
| Max. Negotiated Rate |
$457.35 |
| Rate for Payer: Aetna Commercial |
$447.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$427.52
|
| Rate for Payer: Aetna Managed Medicare |
$139.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$248.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$238.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.47
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$457.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.20
|
| Rate for Payer: Health EOS Commercial |
$442.44
|
| Rate for Payer: HFN Commercial |
$457.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.84
|
| Rate for Payer: Multiplan Commercial |
$397.70
|
| Rate for Payer: NAPHCARE Commercial |
$298.27
|
| Rate for Payer: Preferred Network Access Commercial |
$457.35
|
| Rate for Payer: Quartz Beloit One Network |
$243.59
|
| Rate for Payer: Quartz Commercial |
$323.13
|
| Rate for Payer: Quartz Medicare Advantage |
$298.27
|
| Rate for Payer: The Alliance Commercial |
$248.56
|
| Rate for Payer: WEA Trust Commercial |
$273.42
|
| Rate for Payer: WPS Commercial |
$368.20
|
|
|
SPLINT SAM 5 1/2 x36 #5628-77
|
Facility
|
IP
|
$478.00
|
|
| Hospital Charge Code |
2971285
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$243.59 |
| Max. Negotiated Rate |
$457.35 |
| Rate for Payer: Aetna Commercial |
$447.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$427.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.47
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$457.35
|
| Rate for Payer: Health EOS Commercial |
$442.44
|
| Rate for Payer: HFN Commercial |
$457.35
|
| Rate for Payer: Multiplan Commercial |
$397.70
|
| Rate for Payer: Preferred Network Access Commercial |
$457.35
|
| Rate for Payer: Quartz Beloit One Network |
$243.59
|
| Rate for Payer: Quartz Commercial |
$298.27
|
| Rate for Payer: WEA Trust Commercial |
$273.42
|
| Rate for Payer: WPS Commercial |
$368.20
|
|
|
SPLINTS FINGER (AA) #704101
|
Facility
|
IP
|
$406.00
|
|
| Hospital Charge Code |
2969843
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$206.90 |
| Max. Negotiated Rate |
$388.46 |
| Rate for Payer: Aetna Commercial |
$380.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.79
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$388.46
|
| Rate for Payer: Health EOS Commercial |
$375.79
|
| Rate for Payer: HFN Commercial |
$388.46
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: Preferred Network Access Commercial |
$388.46
|
| Rate for Payer: Quartz Beloit One Network |
$206.90
|
| Rate for Payer: Quartz Commercial |
$253.34
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
SPLINTS FINGER (AA) #704101
|
Facility
|
OP
|
$406.00
|
|
| Hospital Charge Code |
2969843
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$118.23 |
| Max. Negotiated Rate |
$388.46 |
| Rate for Payer: Aetna Commercial |
$380.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Aetna Managed Medicare |
$118.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$274.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$211.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$202.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.79
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$388.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.29
|
| Rate for Payer: Health EOS Commercial |
$375.79
|
| Rate for Payer: HFN Commercial |
$388.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$316.68
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: NAPHCARE Commercial |
$253.34
|
| Rate for Payer: Preferred Network Access Commercial |
$388.46
|
| Rate for Payer: Quartz Beloit One Network |
$206.90
|
| Rate for Payer: Quartz Commercial |
$274.46
|
| Rate for Payer: Quartz Medicare Advantage |
$253.34
|
| Rate for Payer: The Alliance Commercial |
$211.12
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
Splint, short arm applied - Treatments Done
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 29125
|
| Hospital Charge Code |
3025944
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$119.76 |
| Max. Negotiated Rate |
$224.85 |
| Rate for Payer: Aetna Commercial |
$219.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.53
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$224.85
|
| Rate for Payer: Health EOS Commercial |
$217.52
|
| Rate for Payer: HFN Commercial |
$224.85
|
| Rate for Payer: Multiplan Commercial |
$195.52
|
| Rate for Payer: Preferred Network Access Commercial |
$224.85
|
| Rate for Payer: Quartz Beloit One Network |
$119.76
|
| Rate for Payer: Quartz Commercial |
$146.64
|
| Rate for Payer: WEA Trust Commercial |
$134.42
|
| Rate for Payer: WPS Commercial |
$181.02
|
|
|
Splint, short arm applied - Treatments Done
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 29125
|
| Hospital Charge Code |
3025944
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$117.31 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$219.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.18
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$158.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$117.31
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$224.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$217.52
|
| Rate for Payer: HFN Commercial |
$224.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$195.52
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$224.85
|
| Rate for Payer: Quartz Beloit One Network |
$119.76
|
| Rate for Payer: Quartz Commercial |
$158.86
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$134.42
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$181.02
|
|
|
Splint, short leg applied - Treatments Done
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
CPT 29515
|
| Hospital Charge Code |
3025943
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$229.83 |
| Max. Negotiated Rate |
$431.52 |
| Rate for Payer: Aetna Commercial |
$422.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$403.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.59
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cigna Commercial |
$431.52
|
| Rate for Payer: Health EOS Commercial |
$417.45
|
| Rate for Payer: HFN Commercial |
$431.52
|
| Rate for Payer: Multiplan Commercial |
$375.23
|
| Rate for Payer: Preferred Network Access Commercial |
$431.52
|
| Rate for Payer: Quartz Beloit One Network |
$229.83
|
| Rate for Payer: Quartz Commercial |
$281.42
|
| Rate for Payer: WEA Trust Commercial |
$257.97
|
| Rate for Payer: WPS Commercial |
$347.41
|
|
|
Splint, short leg applied - Treatments Done
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
CPT 29515
|
| Hospital Charge Code |
3025943
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$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
|
|
|
SPLINTS OVAL - 8 SIZE 11
|
Facility
|
IP
|
$246.00
|
|
| Hospital Charge Code |
2970761
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$125.36 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$153.50
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
SPLINTS OVAL - 8 SIZE 11
|
Facility
|
OP
|
$246.00
|
|
| Hospital Charge Code |
2970761
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Aetna Managed Medicare |
$71.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$166.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$127.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$122.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.17
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.88
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: NAPHCARE Commercial |
$153.50
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$166.30
|
| Rate for Payer: Quartz Medicare Advantage |
$153.50
|
| Rate for Payer: The Alliance Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
SPLINTS OVAL - 8 SIZE 12
|
Facility
|
IP
|
$246.00
|
|
| Hospital Charge Code |
2970762
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$125.36 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$153.50
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
SPLINTS OVAL - 8 SIZE 12
|
Facility
|
OP
|
$246.00
|
|
| Hospital Charge Code |
2970762
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Aetna Managed Medicare |
$71.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$166.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$127.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$122.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.17
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.88
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: NAPHCARE Commercial |
$153.50
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$166.30
|
| Rate for Payer: Quartz Medicare Advantage |
$153.50
|
| Rate for Payer: The Alliance Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
SPLINTS OVAL-8 SZ10 #9272-85-10
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2971296
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
SPLINTS OVAL-8 SZ10 #9272-85-10
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971296
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.19 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$40.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.64
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$86.11
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$86.11
|
| Rate for Payer: The Alliance Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
SPLINTS OVAL-8 SZ 11 92728511
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
3072554
|
|
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
|
|
|
SPLINTS OVAL-8 SZ 11 92728511
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
3072554
|
|
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
|
|
|
SPLINTS OVAL-8 SZ 5 #9272-85-05
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
2971291
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Aetna Managed Medicare |
$36.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$84.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$65.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.75
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.50
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$78.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$84.50
|
| Rate for Payer: Quartz Medicare Advantage |
$78.00
|
| Rate for Payer: The Alliance Commercial |
$65.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
SPLINTS OVAL-8 SZ 5 #9272-85-05
|
Facility
|
IP
|
$125.00
|
|
| Hospital Charge Code |
2971291
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
SPLINTS OVAL-8 SZ 6 #9272-85-06
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971292
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.19 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$40.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.64
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$86.11
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$86.11
|
| Rate for Payer: The Alliance Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
SPLINTS OVAL-8 SZ 6 #9272-85-06
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2971292
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
SPLINTS OVAL-8 SZ 7 #9272-85-07
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
2971293
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
SPLINTS OVAL-8 SZ 7 #9272-85-07
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971293
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.19 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$40.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.64
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$86.11
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$86.11
|
| Rate for Payer: The Alliance Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
SPLINTS OVAL-8 SZ 8 #9272-85-08
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
2971294
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.19 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$40.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.64
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$86.11
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$86.11
|
| Rate for Payer: The Alliance Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
