|
Treanda 1 mg Charge
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
2958920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$61.64 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$40.20
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$40.20
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Treanda 1 mg Charge
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
2958920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.83 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.83
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: HFN Commercial |
$63.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.59
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: The Alliance Commercial |
$33.50
|
| Rate for Payer: United Healthcare Medicaid |
$13.83
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$34.58
|
|
|
TREAT BIG TOE FRACTURE 28496
|
Professional
|
Both
|
$920.00
|
|
|
Service Code
|
CPT 28496
|
| Hospital Charge Code |
3014258
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$207.99 |
| Max. Negotiated Rate |
$874.00 |
| Rate for Payer: Aetna Commercial |
$874.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$791.20
|
| Rate for Payer: Cash Price |
$276.00
|
| Rate for Payer: Cash Price |
$276.00
|
| Rate for Payer: Cash Price |
$276.00
|
| Rate for Payer: Cigna Commercial |
$874.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$207.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$552.00
|
| Rate for Payer: Health EOS Commercial |
$837.20
|
| Rate for Payer: HFN Commercial |
$874.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$820.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$820.58
|
| Rate for Payer: Multiplan Commercial |
$736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$874.00
|
| Rate for Payer: Quartz Beloit One Network |
$404.80
|
| Rate for Payer: Quartz Commercial |
$524.40
|
| Rate for Payer: The Alliance Commercial |
$460.00
|
| Rate for Payer: United Healthcare Medicaid |
$207.99
|
| Rate for Payer: WEA Trust Commercial |
$506.00
|
| Rate for Payer: WPS Commercial |
$681.44
|
|
|
TREAT BIG TOE FRACTURE 28505
|
Professional
|
Both
|
$1,410.00
|
|
|
Service Code
|
CPT 28505
|
| Hospital Charge Code |
3014259
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.95 |
| Rate for Payer: Aetna Commercial |
$1,339.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,212.60
|
| Rate for Payer: Cash Price |
$423.00
|
| Rate for Payer: Cash Price |
$423.00
|
| Rate for Payer: Cash Price |
$423.00
|
| Rate for Payer: Cigna Commercial |
$1,339.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$846.00
|
| Rate for Payer: Health EOS Commercial |
$1,283.10
|
| Rate for Payer: HFN Commercial |
$1,339.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,668.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,668.95
|
| Rate for Payer: Multiplan Commercial |
$1,128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,339.50
|
| Rate for Payer: Quartz Beloit One Network |
$620.40
|
| Rate for Payer: Quartz Commercial |
$803.70
|
| Rate for Payer: The Alliance Commercial |
$705.00
|
| Rate for Payer: United Healthcare Medicaid |
$226.00
|
| Rate for Payer: WEA Trust Commercial |
$775.50
|
| Rate for Payer: WPS Commercial |
$1,044.39
|
|
|
TREAT CHEEK BONE FRACTURE 21356
|
Professional
|
Both
|
$2,726.00
|
|
|
Service Code
|
CPT 21356
|
| Hospital Charge Code |
3013732
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$404.73 |
| Max. Negotiated Rate |
$2,589.70 |
| Rate for Payer: Aetna Commercial |
$2,589.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,344.36
|
| Rate for Payer: Cash Price |
$817.80
|
| Rate for Payer: Cash Price |
$817.80
|
| Rate for Payer: Cash Price |
$817.80
|
| Rate for Payer: Cigna Commercial |
$2,589.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$404.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,635.60
|
| Rate for Payer: Health EOS Commercial |
$2,480.66
|
| Rate for Payer: HFN Commercial |
$2,589.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,262.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,262.08
|
| Rate for Payer: Multiplan Commercial |
$2,180.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,589.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,199.44
|
| Rate for Payer: Quartz Commercial |
$1,553.82
|
| Rate for Payer: The Alliance Commercial |
$1,363.00
|
| Rate for Payer: United Healthcare Medicaid |
$404.73
|
| Rate for Payer: WEA Trust Commercial |
$1,499.30
|
| Rate for Payer: WPS Commercial |
$2,019.15
|
|
|
TREAT CLAVICLE FRACTURE 23505
|
Professional
|
Both
|
$1,499.00
|
|
|
Service Code
|
CPT 23505
|
| Hospital Charge Code |
3013782
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,424.05 |
| Rate for Payer: Aetna Commercial |
$1,424.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,289.14
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cash Price |
$449.70
|
| Rate for Payer: Cigna Commercial |
$1,424.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$899.40
|
| Rate for Payer: Health EOS Commercial |
$1,364.09
|
| Rate for Payer: HFN Commercial |
$1,424.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,116.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,116.01
|
| Rate for Payer: Multiplan Commercial |
$1,199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,424.05
|
| Rate for Payer: Quartz Beloit One Network |
$659.56
|
| Rate for Payer: Quartz Commercial |
$854.43
|
| Rate for Payer: The Alliance Commercial |
$749.50
|
| Rate for Payer: United Healthcare Medicaid |
$226.00
|
| Rate for Payer: WEA Trust Commercial |
$824.45
|
| Rate for Payer: WPS Commercial |
$1,110.31
|
|
|
TREAT ELBOW DISLOCATION 24600
|
Professional
|
Both
|
$1,011.00
|
|
|
Service Code
|
CPT 24600
|
| Hospital Charge Code |
3013844
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.33 |
| Max. Negotiated Rate |
$1,124.23 |
| Rate for Payer: Aetna Commercial |
$960.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$869.46
|
| Rate for Payer: Cash Price |
$303.30
|
| Rate for Payer: Cash Price |
$303.30
|
| Rate for Payer: Cash Price |
$303.30
|
| Rate for Payer: Cigna Commercial |
$960.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.60
|
| Rate for Payer: Health EOS Commercial |
$920.01
|
| Rate for Payer: HFN Commercial |
$960.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,124.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,124.23
|
| Rate for Payer: Multiplan Commercial |
$808.80
|
| Rate for Payer: Preferred Network Access Commercial |
$960.45
|
| Rate for Payer: Quartz Beloit One Network |
$444.84
|
| Rate for Payer: Quartz Commercial |
$576.27
|
| Rate for Payer: The Alliance Commercial |
$505.50
|
| Rate for Payer: United Healthcare Medicaid |
$75.33
|
| Rate for Payer: WEA Trust Commercial |
$556.05
|
| Rate for Payer: WPS Commercial |
$748.85
|
|
|
TREAT ELBOW DISLOCATION 24640
|
Professional
|
Both
|
$383.00
|
|
|
Service Code
|
CPT 24640
|
| Hospital Charge Code |
3013847
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.04 |
| Max. Negotiated Rate |
$363.85 |
| Rate for Payer: Aetna Commercial |
$363.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$363.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.80
|
| Rate for Payer: Health EOS Commercial |
$348.53
|
| Rate for Payer: HFN Commercial |
$363.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$272.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$272.13
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: Preferred Network Access Commercial |
$363.85
|
| Rate for Payer: Quartz Beloit One Network |
$168.52
|
| Rate for Payer: Quartz Commercial |
$218.31
|
| Rate for Payer: The Alliance Commercial |
$191.50
|
| Rate for Payer: United Healthcare Medicaid |
$61.04
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
TREAT EYELID LESION 67850
|
Professional
|
Both
|
$626.00
|
|
|
Service Code
|
CPT 67850
|
| Hospital Charge Code |
3015245
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.54 |
| Max. Negotiated Rate |
$594.70 |
| Rate for Payer: Aetna Commercial |
$594.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.36
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$594.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$375.60
|
| Rate for Payer: Health EOS Commercial |
$569.66
|
| Rate for Payer: HFN Commercial |
$594.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$439.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$439.87
|
| Rate for Payer: Multiplan Commercial |
$500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$594.70
|
| Rate for Payer: Quartz Beloit One Network |
$275.44
|
| Rate for Payer: Quartz Commercial |
$356.82
|
| Rate for Payer: The Alliance Commercial |
$313.00
|
| Rate for Payer: United Healthcare Medicaid |
$52.54
|
| Rate for Payer: WEA Trust Commercial |
$344.30
|
| Rate for Payer: WPS Commercial |
$463.68
|
|
|
TREAT FINGER DISLOCATION 26770
|
Professional
|
Both
|
$691.00
|
|
|
Service Code
|
CPT 26770
|
| Hospital Charge Code |
3013991
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.38 |
| Max. Negotiated Rate |
$866.23 |
| Rate for Payer: Aetna Commercial |
$656.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$594.26
|
| Rate for Payer: Cash Price |
$207.30
|
| Rate for Payer: Cash Price |
$207.30
|
| Rate for Payer: Cash Price |
$207.30
|
| Rate for Payer: Cigna Commercial |
$656.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$414.60
|
| Rate for Payer: Health EOS Commercial |
$628.81
|
| Rate for Payer: HFN Commercial |
$656.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$866.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$866.23
|
| Rate for Payer: Multiplan Commercial |
$552.80
|
| Rate for Payer: Preferred Network Access Commercial |
$656.45
|
| Rate for Payer: Quartz Beloit One Network |
$304.04
|
| Rate for Payer: Quartz Commercial |
$393.87
|
| Rate for Payer: The Alliance Commercial |
$345.50
|
| Rate for Payer: United Healthcare Medicaid |
$73.38
|
| Rate for Payer: WEA Trust Commercial |
$380.05
|
| Rate for Payer: WPS Commercial |
$511.82
|
|
|
TREAT FINGER DISLOCATION 26775
|
Professional
|
Both
|
$866.00
|
|
|
Service Code
|
CPT 26775
|
| Hospital Charge Code |
3013992
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$94.19 |
| Max. Negotiated Rate |
$1,181.56 |
| Rate for Payer: Aetna Commercial |
$822.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$744.76
|
| Rate for Payer: Cash Price |
$259.80
|
| Rate for Payer: Cash Price |
$259.80
|
| Rate for Payer: Cash Price |
$259.80
|
| Rate for Payer: Cigna Commercial |
$822.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$94.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$519.60
|
| Rate for Payer: Health EOS Commercial |
$788.06
|
| Rate for Payer: HFN Commercial |
$822.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,181.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,181.56
|
| Rate for Payer: Multiplan Commercial |
$692.80
|
| Rate for Payer: Preferred Network Access Commercial |
$822.70
|
| Rate for Payer: Quartz Beloit One Network |
$381.04
|
| Rate for Payer: Quartz Commercial |
$493.62
|
| Rate for Payer: The Alliance Commercial |
$433.00
|
| Rate for Payer: United Healthcare Medicaid |
$94.19
|
| Rate for Payer: WEA Trust Commercial |
$476.30
|
| Rate for Payer: WPS Commercial |
$641.45
|
|
|
Treat Finger Fracture, Each 26742
|
Professional
|
Both
|
$1,925.00
|
|
|
Service Code
|
CPT 26742
|
| Hospital Charge Code |
3935372
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$165.15 |
| Max. Negotiated Rate |
$1,828.75 |
| Rate for Payer: Aetna Commercial |
$1,828.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,655.50
|
| Rate for Payer: Cash Price |
$577.50
|
| Rate for Payer: Cash Price |
$577.50
|
| Rate for Payer: Cash Price |
$577.50
|
| Rate for Payer: Cigna Commercial |
$1,828.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$165.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,155.00
|
| Rate for Payer: Health EOS Commercial |
$1,751.75
|
| Rate for Payer: HFN Commercial |
$1,828.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,131.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,131.08
|
| Rate for Payer: Multiplan Commercial |
$1,540.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,828.75
|
| Rate for Payer: Quartz Beloit One Network |
$847.00
|
| Rate for Payer: Quartz Commercial |
$1,097.25
|
| Rate for Payer: The Alliance Commercial |
$962.50
|
| Rate for Payer: United Healthcare Medicaid |
$165.15
|
| Rate for Payer: WEA Trust Commercial |
$1,058.75
|
| Rate for Payer: WPS Commercial |
$1,425.85
|
|
|
TREAT FINGER FRACTURE, EACH 26750
|
Professional
|
Both
|
$363.00
|
|
|
Service Code
|
CPT 26750
|
| Hospital Charge Code |
3013987
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.94 |
| Max. Negotiated Rate |
$632.08 |
| Rate for Payer: Aetna Commercial |
$344.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.18
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cigna Commercial |
$344.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.80
|
| Rate for Payer: Health EOS Commercial |
$330.33
|
| Rate for Payer: HFN Commercial |
$344.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$632.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$632.08
|
| Rate for Payer: Multiplan Commercial |
$290.40
|
| Rate for Payer: Preferred Network Access Commercial |
$344.85
|
| Rate for Payer: Quartz Beloit One Network |
$159.72
|
| Rate for Payer: Quartz Commercial |
$206.91
|
| Rate for Payer: The Alliance Commercial |
$181.50
|
| Rate for Payer: United Healthcare Medicaid |
$57.94
|
| Rate for Payer: WEA Trust Commercial |
$199.65
|
| Rate for Payer: WPS Commercial |
$268.87
|
|
|
TREAT FINGER FRACTURE, EACH 26755
|
Professional
|
Both
|
$480.00
|
|
|
Service Code
|
CPT 26755
|
| Hospital Charge Code |
3013988
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.28 |
| Max. Negotiated Rate |
$922.07 |
| Rate for Payer: Aetna Commercial |
$456.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.80
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.00
|
| Rate for Payer: Health EOS Commercial |
$436.80
|
| Rate for Payer: HFN Commercial |
$456.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$922.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$922.07
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: Preferred Network Access Commercial |
$456.00
|
| Rate for Payer: Quartz Beloit One Network |
$211.20
|
| Rate for Payer: Quartz Commercial |
$273.60
|
| Rate for Payer: The Alliance Commercial |
$240.00
|
| Rate for Payer: United Healthcare Medicaid |
$62.28
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
TREAT FOOT DISLOCATION 28545
|
Professional
|
Both
|
$564.00
|
|
|
Service Code
|
CPT 28545
|
| Hospital Charge Code |
3014264
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$150.66 |
| Max. Negotiated Rate |
$900.79 |
| Rate for Payer: Aetna Commercial |
$535.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.04
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cigna Commercial |
$535.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$338.40
|
| Rate for Payer: Health EOS Commercial |
$513.24
|
| Rate for Payer: HFN Commercial |
$535.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$900.79
|
| Rate for Payer: Multiplan Commercial |
$451.20
|
| Rate for Payer: Preferred Network Access Commercial |
$535.80
|
| Rate for Payer: Quartz Beloit One Network |
$248.16
|
| Rate for Payer: Quartz Commercial |
$321.48
|
| Rate for Payer: The Alliance Commercial |
$282.00
|
| Rate for Payer: United Healthcare Medicaid |
$150.66
|
| Rate for Payer: WEA Trust Commercial |
$310.20
|
| Rate for Payer: WPS Commercial |
$417.75
|
|
|
TREAT FOOT DISLOCATION 28600
|
Professional
|
Both
|
$564.00
|
|
|
Service Code
|
CPT 28600
|
| Hospital Charge Code |
3014268
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$105.45 |
| Max. Negotiated Rate |
$624.95 |
| Rate for Payer: Aetna Commercial |
$535.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.04
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cigna Commercial |
$535.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$105.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$338.40
|
| Rate for Payer: Health EOS Commercial |
$513.24
|
| Rate for Payer: HFN Commercial |
$535.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$624.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$624.95
|
| Rate for Payer: Multiplan Commercial |
$451.20
|
| Rate for Payer: Preferred Network Access Commercial |
$535.80
|
| Rate for Payer: Quartz Beloit One Network |
$248.16
|
| Rate for Payer: Quartz Commercial |
$321.48
|
| Rate for Payer: The Alliance Commercial |
$282.00
|
| Rate for Payer: United Healthcare Medicaid |
$105.45
|
| Rate for Payer: WEA Trust Commercial |
$310.20
|
| Rate for Payer: WPS Commercial |
$417.75
|
|
|
TREAT FRACTURE OF RADIUS 25505
|
Professional
|
Both
|
$1,886.00
|
|
|
Service Code
|
CPT 25505
|
| Hospital Charge Code |
3013891
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$301.31 |
| Max. Negotiated Rate |
$1,791.70 |
| Rate for Payer: Aetna Commercial |
$1,791.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,621.96
|
| Rate for Payer: Cash Price |
$565.80
|
| Rate for Payer: Cash Price |
$565.80
|
| Rate for Payer: Cash Price |
$565.80
|
| Rate for Payer: Cigna Commercial |
$1,791.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$301.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,131.60
|
| Rate for Payer: Health EOS Commercial |
$1,716.26
|
| Rate for Payer: HFN Commercial |
$1,791.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,534.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,534.99
|
| Rate for Payer: Multiplan Commercial |
$1,508.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,791.70
|
| Rate for Payer: Quartz Beloit One Network |
$829.84
|
| Rate for Payer: Quartz Commercial |
$1,075.02
|
| Rate for Payer: The Alliance Commercial |
$943.00
|
| Rate for Payer: United Healthcare Medicaid |
$301.31
|
| Rate for Payer: WEA Trust Commercial |
$1,037.30
|
| Rate for Payer: WPS Commercial |
$1,396.96
|
|
|
TREAT FRACTURE OF RADIUS 25520
|
Professional
|
Both
|
$2,207.00
|
|
|
Service Code
|
CPT 25520
|
| Hospital Charge Code |
3013893
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$475.82 |
| Max. Negotiated Rate |
$2,096.65 |
| Rate for Payer: Aetna Commercial |
$2,096.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,898.02
|
| Rate for Payer: Cash Price |
$662.10
|
| Rate for Payer: Cash Price |
$662.10
|
| Rate for Payer: Cash Price |
$662.10
|
| Rate for Payer: Cigna Commercial |
$2,096.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$475.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,324.20
|
| Rate for Payer: Health EOS Commercial |
$2,008.37
|
| Rate for Payer: HFN Commercial |
$2,096.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,815.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,815.69
|
| Rate for Payer: Multiplan Commercial |
$1,765.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,096.65
|
| Rate for Payer: Quartz Beloit One Network |
$971.08
|
| Rate for Payer: Quartz Commercial |
$1,257.99
|
| Rate for Payer: The Alliance Commercial |
$1,103.50
|
| Rate for Payer: United Healthcare Medicaid |
$475.82
|
| Rate for Payer: WEA Trust Commercial |
$1,213.85
|
| Rate for Payer: WPS Commercial |
$1,634.72
|
|
|
TREAT FRACTURE OF ULNA 25535
|
Professional
|
Both
|
$1,169.00
|
|
|
Service Code
|
CPT 25535
|
| Hospital Charge Code |
3013897
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$301.31 |
| Max. Negotiated Rate |
$1,533.15 |
| Rate for Payer: Aetna Commercial |
$1,110.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,005.34
|
| Rate for Payer: Cash Price |
$350.70
|
| Rate for Payer: Cash Price |
$350.70
|
| Rate for Payer: Cash Price |
$350.70
|
| Rate for Payer: Cigna Commercial |
$1,110.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$301.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$701.40
|
| Rate for Payer: Health EOS Commercial |
$1,063.79
|
| Rate for Payer: HFN Commercial |
$1,110.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,533.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,533.15
|
| Rate for Payer: Multiplan Commercial |
$935.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,110.55
|
| Rate for Payer: Quartz Beloit One Network |
$514.36
|
| Rate for Payer: Quartz Commercial |
$666.33
|
| Rate for Payer: The Alliance Commercial |
$584.50
|
| Rate for Payer: United Healthcare Medicaid |
$301.31
|
| Rate for Payer: WEA Trust Commercial |
$642.95
|
| Rate for Payer: WPS Commercial |
$865.88
|
|
|
TREAT FRACTURE RADIUS AND ULNA 25565
|
Professional
|
Both
|
$1,947.00
|
|
|
Service Code
|
CPT 25565
|
| Hospital Charge Code |
3013900
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$389.13 |
| Max. Negotiated Rate |
$1,849.65 |
| Rate for Payer: Aetna Commercial |
$1,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,674.42
|
| Rate for Payer: Cash Price |
$584.10
|
| Rate for Payer: Cash Price |
$584.10
|
| Rate for Payer: Cash Price |
$584.10
|
| Rate for Payer: Cigna Commercial |
$1,849.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$389.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,168.20
|
| Rate for Payer: Health EOS Commercial |
$1,771.77
|
| Rate for Payer: HFN Commercial |
$1,849.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,549.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,549.18
|
| Rate for Payer: Multiplan Commercial |
$1,557.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,849.65
|
| Rate for Payer: Quartz Beloit One Network |
$856.68
|
| Rate for Payer: Quartz Commercial |
$1,109.79
|
| Rate for Payer: The Alliance Commercial |
$973.50
|
| Rate for Payer: United Healthcare Medicaid |
$389.13
|
| Rate for Payer: WEA Trust Commercial |
$1,070.85
|
| Rate for Payer: WPS Commercial |
$1,442.14
|
|
|
TREAT FRACTURE RADIUS/ULNA 25605
|
Professional
|
Both
|
$913.00
|
|
|
Service Code
|
CPT 25605
|
| Hospital Charge Code |
3013904
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$380.69 |
| Max. Negotiated Rate |
$1,706.15 |
| Rate for Payer: Aetna Commercial |
$867.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$785.18
|
| Rate for Payer: Cash Price |
$273.90
|
| Rate for Payer: Cash Price |
$273.90
|
| Rate for Payer: Cash Price |
$273.90
|
| Rate for Payer: Cigna Commercial |
$867.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$380.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.80
|
| Rate for Payer: Health EOS Commercial |
$830.83
|
| Rate for Payer: HFN Commercial |
$867.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,706.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,706.15
|
| Rate for Payer: Multiplan Commercial |
$730.40
|
| Rate for Payer: Preferred Network Access Commercial |
$867.35
|
| Rate for Payer: Quartz Beloit One Network |
$401.72
|
| Rate for Payer: Quartz Commercial |
$520.41
|
| Rate for Payer: The Alliance Commercial |
$456.50
|
| Rate for Payer: United Healthcare Medicaid |
$380.69
|
| Rate for Payer: WEA Trust Commercial |
$502.15
|
| Rate for Payer: WPS Commercial |
$676.26
|
|
|
TREAT HAND DISLOCATION 26675
|
Professional
|
Both
|
$1,262.00
|
|
|
Service Code
|
CPT 26675
|
| Hospital Charge Code |
3013976
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$120.52 |
| Max. Negotiated Rate |
$1,411.15 |
| Rate for Payer: Aetna Commercial |
$1,198.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,085.32
|
| Rate for Payer: Cash Price |
$378.60
|
| Rate for Payer: Cash Price |
$378.60
|
| Rate for Payer: Cash Price |
$378.60
|
| Rate for Payer: Cigna Commercial |
$1,198.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$757.20
|
| Rate for Payer: Health EOS Commercial |
$1,148.42
|
| Rate for Payer: HFN Commercial |
$1,198.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,411.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,411.15
|
| Rate for Payer: Multiplan Commercial |
$1,009.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,198.90
|
| Rate for Payer: Quartz Beloit One Network |
$555.28
|
| Rate for Payer: Quartz Commercial |
$719.34
|
| Rate for Payer: The Alliance Commercial |
$631.00
|
| Rate for Payer: United Healthcare Medicaid |
$120.52
|
| Rate for Payer: WEA Trust Commercial |
$694.10
|
| Rate for Payer: WPS Commercial |
$934.76
|
|
|
TREAT HIP SOCKET FRACTURE 27220
|
Professional
|
Both
|
$1,334.00
|
|
|
Service Code
|
CPT 27220
|
| Hospital Charge Code |
3014028
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$376.66 |
| Max. Negotiated Rate |
$1,368.48 |
| Rate for Payer: Aetna Commercial |
$1,267.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,147.24
|
| Rate for Payer: Cash Price |
$400.20
|
| Rate for Payer: Cash Price |
$400.20
|
| Rate for Payer: Cash Price |
$400.20
|
| Rate for Payer: Cigna Commercial |
$1,267.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$376.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$800.40
|
| Rate for Payer: Health EOS Commercial |
$1,213.94
|
| Rate for Payer: HFN Commercial |
$1,267.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,368.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,368.48
|
| Rate for Payer: Multiplan Commercial |
$1,067.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,267.30
|
| Rate for Payer: Quartz Beloit One Network |
$586.96
|
| Rate for Payer: Quartz Commercial |
$760.38
|
| Rate for Payer: The Alliance Commercial |
$667.00
|
| Rate for Payer: United Healthcare Medicaid |
$376.66
|
| Rate for Payer: WEA Trust Commercial |
$733.70
|
| Rate for Payer: WPS Commercial |
$988.09
|
|
|
TREAT HUMERUS FRACTURE 23605
|
Professional
|
Both
|
$1,512.00
|
|
|
Service Code
|
CPT 23605
|
| Hospital Charge Code |
3013790
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$452.00 |
| Max. Negotiated Rate |
$1,436.40 |
| Rate for Payer: Aetna Commercial |
$1,436.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,300.32
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cigna Commercial |
$1,436.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$452.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$907.20
|
| Rate for Payer: Health EOS Commercial |
$1,375.92
|
| Rate for Payer: HFN Commercial |
$1,436.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,429.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,429.72
|
| Rate for Payer: Multiplan Commercial |
$1,209.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,436.40
|
| Rate for Payer: Quartz Beloit One Network |
$665.28
|
| Rate for Payer: Quartz Commercial |
$861.84
|
| Rate for Payer: The Alliance Commercial |
$756.00
|
| Rate for Payer: United Healthcare Medicaid |
$452.00
|
| Rate for Payer: WEA Trust Commercial |
$831.60
|
| Rate for Payer: WPS Commercial |
$1,119.94
|
|
|
TREAT HUMERUS FRACTURE 24505
|
Professional
|
Both
|
$1,562.00
|
|
|
Service Code
|
CPT 24505
|
| Hospital Charge Code |
3013831
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$376.66 |
| Max. Negotiated Rate |
$1,510.49 |
| Rate for Payer: Aetna Commercial |
$1,483.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,343.32
|
| Rate for Payer: Cash Price |
$468.60
|
| Rate for Payer: Cash Price |
$468.60
|
| Rate for Payer: Cash Price |
$468.60
|
| Rate for Payer: Cigna Commercial |
$1,483.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$376.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$937.20
|
| Rate for Payer: Health EOS Commercial |
$1,421.42
|
| Rate for Payer: HFN Commercial |
$1,483.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,510.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,510.49
|
| Rate for Payer: Multiplan Commercial |
$1,249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,483.90
|
| Rate for Payer: Quartz Beloit One Network |
$687.28
|
| Rate for Payer: Quartz Commercial |
$890.34
|
| Rate for Payer: The Alliance Commercial |
$781.00
|
| Rate for Payer: United Healthcare Medicaid |
$376.66
|
| Rate for Payer: WEA Trust Commercial |
$859.10
|
| Rate for Payer: WPS Commercial |
$1,156.97
|
|
