|
BRACE ANKLE STANDARD LRG/RT
|
Facility
|
IP
|
$384.00
|
|
| Hospital Charge Code |
2969660
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$188.16 |
| Max. Negotiated Rate |
$353.28 |
| Rate for Payer: Aetna Commercial |
$345.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.52
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$353.28
|
| Rate for Payer: Health EOS Commercial |
$341.76
|
| Rate for Payer: HFN Commercial |
$353.28
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: NAPHCARE Commercial |
$230.40
|
| Rate for Payer: Preferred Network Access Commercial |
$353.28
|
| Rate for Payer: Quartz Beloit One Network |
$188.16
|
| Rate for Payer: Quartz Commercial |
$230.40
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
|
BRACE ELBOW IROM LARGE LEFT
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
2972034
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$546.35 |
| Max. Negotiated Rate |
$1,025.80 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$669.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
BRACE ELBOW IROM LARGE LEFT
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
2972034
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$312.20 |
| Max. Negotiated Rate |
$4,460.00 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Aetna Managed Medicare |
$312.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$724.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$557.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$535.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$623.95
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$836.25
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$724.75
|
| Rate for Payer: Quartz Medicare Advantage |
$669.00
|
| Rate for Payer: The Alliance Commercial |
$4,460.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
BRACE ELBOW IROM LARGE RIGHT
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
2972032
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$312.20 |
| Max. Negotiated Rate |
$4,460.00 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Aetna Managed Medicare |
$312.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$724.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$557.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$535.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$623.95
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$836.25
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$724.75
|
| Rate for Payer: Quartz Medicare Advantage |
$669.00
|
| Rate for Payer: The Alliance Commercial |
$4,460.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
BRACE ELBOW IROM LARGE RIGHT
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
2972032
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$546.35 |
| Max. Negotiated Rate |
$1,025.80 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$669.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
BRACE ELBOW IROM SMALL LEFT
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
2972033
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$312.20 |
| Max. Negotiated Rate |
$4,460.00 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Aetna Managed Medicare |
$312.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$724.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$557.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$535.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$623.95
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$836.25
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$724.75
|
| Rate for Payer: Quartz Medicare Advantage |
$669.00
|
| Rate for Payer: The Alliance Commercial |
$4,460.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
BRACE ELBOW IROM SMALL LEFT
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
2972033
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$546.35 |
| Max. Negotiated Rate |
$1,025.80 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$669.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
BRACE ELBOW IROM SMALL RIGHT
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
2964470
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$546.35 |
| Max. Negotiated Rate |
$1,025.80 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$669.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
BRACE ELBOW IROM SMALL RIGHT
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
2964470
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$312.20 |
| Max. Negotiated Rate |
$4,460.00 |
| Rate for Payer: Aetna Commercial |
$1,003.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$958.90
|
| Rate for Payer: Aetna Managed Medicare |
$312.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$724.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$557.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$535.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$590.95
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,025.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$623.95
|
| Rate for Payer: Health EOS Commercial |
$992.35
|
| Rate for Payer: HFN Commercial |
$1,025.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$836.25
|
| Rate for Payer: Multiplan Commercial |
$892.00
|
| Rate for Payer: NAPHCARE Commercial |
$669.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,025.80
|
| Rate for Payer: Quartz Beloit One Network |
$546.35
|
| Rate for Payer: Quartz Commercial |
$724.75
|
| Rate for Payer: Quartz Medicare Advantage |
$669.00
|
| Rate for Payer: The Alliance Commercial |
$4,460.00
|
| Rate for Payer: WEA Trust Commercial |
$613.25
|
| Rate for Payer: WPS Commercial |
$825.88
|
|
|
BRACE FOOTDROPS ADJUST
|
Facility
|
IP
|
$1,021.00
|
|
| Hospital Charge Code |
2971931
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$500.29 |
| Max. Negotiated Rate |
$939.32 |
| Rate for Payer: Aetna Commercial |
$918.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$878.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$541.13
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cigna Commercial |
$939.32
|
| Rate for Payer: Health EOS Commercial |
$908.69
|
| Rate for Payer: HFN Commercial |
$939.32
|
| Rate for Payer: Multiplan Commercial |
$816.80
|
| Rate for Payer: NAPHCARE Commercial |
$612.60
|
| Rate for Payer: Preferred Network Access Commercial |
$939.32
|
| Rate for Payer: Quartz Beloit One Network |
$500.29
|
| Rate for Payer: Quartz Commercial |
$612.60
|
| Rate for Payer: WEA Trust Commercial |
$561.55
|
| Rate for Payer: WPS Commercial |
$756.25
|
|
|
BRACE FOOTDROPS ADJUST
|
Facility
|
OP
|
$1,021.00
|
|
| Hospital Charge Code |
2971931
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$285.88 |
| Max. Negotiated Rate |
$4,084.00 |
| Rate for Payer: Aetna Commercial |
$918.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$878.06
|
| Rate for Payer: Aetna Managed Medicare |
$285.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$663.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$510.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$490.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$541.13
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cigna Commercial |
$939.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$571.35
|
| Rate for Payer: Health EOS Commercial |
$908.69
|
| Rate for Payer: HFN Commercial |
$939.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$765.75
|
| Rate for Payer: Multiplan Commercial |
$816.80
|
| Rate for Payer: NAPHCARE Commercial |
$612.60
|
| Rate for Payer: Preferred Network Access Commercial |
$939.32
|
| Rate for Payer: Quartz Beloit One Network |
$500.29
|
| Rate for Payer: Quartz Commercial |
$663.65
|
| Rate for Payer: Quartz Medicare Advantage |
$612.60
|
| Rate for Payer: The Alliance Commercial |
$4,084.00
|
| Rate for Payer: WEA Trust Commercial |
$561.55
|
| Rate for Payer: WPS Commercial |
$756.25
|
|
|
BRACE HUMERAL #L3980
|
Facility
|
IP
|
$3,719.00
|
|
| Hospital Charge Code |
2974045
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,822.31 |
| Max. Negotiated Rate |
$3,421.48 |
| Rate for Payer: Aetna Commercial |
$3,347.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,971.07
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,421.48
|
| Rate for Payer: Health EOS Commercial |
$3,309.91
|
| Rate for Payer: HFN Commercial |
$3,421.48
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,231.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,421.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,822.31
|
| Rate for Payer: Quartz Commercial |
$2,231.40
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
BRACE HUMERAL #L3980
|
Facility
|
OP
|
$3,719.00
|
|
| Hospital Charge Code |
2974045
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,041.32 |
| Max. Negotiated Rate |
$14,876.00 |
| Rate for Payer: Aetna Commercial |
$3,347.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,041.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,417.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,859.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,785.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,971.07
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,421.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,081.15
|
| Rate for Payer: Health EOS Commercial |
$3,309.91
|
| Rate for Payer: HFN Commercial |
$3,421.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,789.25
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,231.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,421.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,822.31
|
| Rate for Payer: Quartz Commercial |
$2,417.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,231.40
|
| Rate for Payer: The Alliance Commercial |
$14,876.00
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
BRACE KNEE LG 5674-BLK-L
|
Facility
|
IP
|
$1,025.00
|
|
| Hospital Charge Code |
3072450
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$502.25 |
| Max. Negotiated Rate |
$943.00 |
| Rate for Payer: Aetna Commercial |
$922.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$881.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$543.25
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$943.00
|
| Rate for Payer: Health EOS Commercial |
$912.25
|
| Rate for Payer: HFN Commercial |
$943.00
|
| Rate for Payer: Multiplan Commercial |
$820.00
|
| Rate for Payer: NAPHCARE Commercial |
$615.00
|
| Rate for Payer: Preferred Network Access Commercial |
$943.00
|
| Rate for Payer: Quartz Beloit One Network |
$502.25
|
| Rate for Payer: Quartz Commercial |
$615.00
|
| Rate for Payer: WEA Trust Commercial |
$563.75
|
| Rate for Payer: WPS Commercial |
$759.22
|
|
|
BRACE KNEE LG 5674-BLK-L
|
Facility
|
OP
|
$1,025.00
|
|
| Hospital Charge Code |
3072450
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$287.00 |
| Max. Negotiated Rate |
$4,100.00 |
| Rate for Payer: Aetna Commercial |
$922.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$881.50
|
| Rate for Payer: Aetna Managed Medicare |
$287.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$666.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$512.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$492.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$543.25
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$943.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$573.59
|
| Rate for Payer: Health EOS Commercial |
$912.25
|
| Rate for Payer: HFN Commercial |
$943.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$768.75
|
| Rate for Payer: Multiplan Commercial |
$820.00
|
| Rate for Payer: NAPHCARE Commercial |
$615.00
|
| Rate for Payer: Preferred Network Access Commercial |
$943.00
|
| Rate for Payer: Quartz Beloit One Network |
$502.25
|
| Rate for Payer: Quartz Commercial |
$666.25
|
| Rate for Payer: Quartz Medicare Advantage |
$615.00
|
| Rate for Payer: The Alliance Commercial |
$4,100.00
|
| Rate for Payer: WEA Trust Commercial |
$563.75
|
| Rate for Payer: WPS Commercial |
$759.22
|
|
|
BRACE SUMIT L0456
|
Facility
|
OP
|
$4,951.00
|
|
| Hospital Charge Code |
2974112
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,386.28 |
| Max. Negotiated Rate |
$19,804.00 |
| Rate for Payer: Aetna Commercial |
$4,455.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,257.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,386.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,218.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,475.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,376.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,624.03
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,554.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,770.58
|
| Rate for Payer: Health EOS Commercial |
$4,406.39
|
| Rate for Payer: HFN Commercial |
$4,554.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,713.25
|
| Rate for Payer: Multiplan Commercial |
$3,960.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,970.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,554.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,425.99
|
| Rate for Payer: Quartz Commercial |
$3,218.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,970.60
|
| Rate for Payer: The Alliance Commercial |
$19,804.00
|
| Rate for Payer: WEA Trust Commercial |
$2,723.05
|
| Rate for Payer: WPS Commercial |
$3,667.21
|
|
|
BRACE SUMIT L0456
|
Facility
|
IP
|
$4,951.00
|
|
| Hospital Charge Code |
2974112
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,425.99 |
| Max. Negotiated Rate |
$4,554.92 |
| Rate for Payer: Aetna Commercial |
$4,455.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,257.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,624.03
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,554.92
|
| Rate for Payer: Health EOS Commercial |
$4,406.39
|
| Rate for Payer: HFN Commercial |
$4,554.92
|
| Rate for Payer: Multiplan Commercial |
$3,960.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,970.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,554.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,425.99
|
| Rate for Payer: Quartz Commercial |
$2,970.60
|
| Rate for Payer: WEA Trust Commercial |
$2,723.05
|
| Rate for Payer: WPS Commercial |
$3,667.21
|
|
|
BRACE THUMB SPICA MED/RIGHT #350MR
|
Facility
|
IP
|
$425.00
|
|
| Hospital Charge Code |
2969593
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$208.25 |
| Max. Negotiated Rate |
$391.00 |
| Rate for Payer: Aetna Commercial |
$382.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$365.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.25
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$391.00
|
| Rate for Payer: Health EOS Commercial |
$378.25
|
| Rate for Payer: HFN Commercial |
$391.00
|
| Rate for Payer: Multiplan Commercial |
$340.00
|
| Rate for Payer: NAPHCARE Commercial |
$255.00
|
| Rate for Payer: Preferred Network Access Commercial |
$391.00
|
| Rate for Payer: Quartz Beloit One Network |
$208.25
|
| Rate for Payer: Quartz Commercial |
$255.00
|
| Rate for Payer: WEA Trust Commercial |
$233.75
|
| Rate for Payer: WPS Commercial |
$314.80
|
|
|
BRACE THUMB SPICA MED/RIGHT #350MR
|
Facility
|
OP
|
$425.00
|
|
| Hospital Charge Code |
2969593
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$1,700.00 |
| Rate for Payer: Aetna Commercial |
$382.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$365.50
|
| Rate for Payer: Aetna Managed Medicare |
$119.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$276.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$212.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$204.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.25
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$391.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$237.83
|
| Rate for Payer: Health EOS Commercial |
$378.25
|
| Rate for Payer: HFN Commercial |
$391.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$318.75
|
| Rate for Payer: Multiplan Commercial |
$340.00
|
| Rate for Payer: NAPHCARE Commercial |
$255.00
|
| Rate for Payer: Preferred Network Access Commercial |
$391.00
|
| Rate for Payer: Quartz Beloit One Network |
$208.25
|
| Rate for Payer: Quartz Commercial |
$276.25
|
| Rate for Payer: Quartz Medicare Advantage |
$255.00
|
| Rate for Payer: The Alliance Commercial |
$1,700.00
|
| Rate for Payer: WEA Trust Commercial |
$233.75
|
| Rate for Payer: WPS Commercial |
$314.80
|
|
|
BRACE THUMB SPICA SML RIGHT
|
Facility
|
OP
|
$425.00
|
|
| Hospital Charge Code |
2969592
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$1,700.00 |
| Rate for Payer: Aetna Commercial |
$382.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$365.50
|
| Rate for Payer: Aetna Managed Medicare |
$119.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$276.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$212.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$204.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.25
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$391.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$237.83
|
| Rate for Payer: Health EOS Commercial |
$378.25
|
| Rate for Payer: HFN Commercial |
$391.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$318.75
|
| Rate for Payer: Multiplan Commercial |
$340.00
|
| Rate for Payer: NAPHCARE Commercial |
$255.00
|
| Rate for Payer: Preferred Network Access Commercial |
$391.00
|
| Rate for Payer: Quartz Beloit One Network |
$208.25
|
| Rate for Payer: Quartz Commercial |
$276.25
|
| Rate for Payer: Quartz Medicare Advantage |
$255.00
|
| Rate for Payer: The Alliance Commercial |
$1,700.00
|
| Rate for Payer: WEA Trust Commercial |
$233.75
|
| Rate for Payer: WPS Commercial |
$314.80
|
|
|
BRACE THUMB SPICA SML RIGHT
|
Facility
|
IP
|
$425.00
|
|
| Hospital Charge Code |
2969592
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$208.25 |
| Max. Negotiated Rate |
$391.00 |
| Rate for Payer: Aetna Commercial |
$382.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$365.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.25
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$391.00
|
| Rate for Payer: Health EOS Commercial |
$378.25
|
| Rate for Payer: HFN Commercial |
$391.00
|
| Rate for Payer: Multiplan Commercial |
$340.00
|
| Rate for Payer: NAPHCARE Commercial |
$255.00
|
| Rate for Payer: Preferred Network Access Commercial |
$391.00
|
| Rate for Payer: Quartz Beloit One Network |
$208.25
|
| Rate for Payer: Quartz Commercial |
$255.00
|
| Rate for Payer: WEA Trust Commercial |
$233.75
|
| Rate for Payer: WPS Commercial |
$314.80
|
|
|
BRACHIAL CLEFT CYST EXCISION
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2959873
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
BRACHIAL CLEFT CYST EXCISION
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2959873
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
BRACHIOPLASTY/BRACHIAL PLEXUS SURGERY
|
Facility
|
IP
|
$12,095.00
|
|
| Hospital Charge Code |
2959871
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,926.55 |
| Max. Negotiated Rate |
$11,127.40 |
| Rate for Payer: Aetna Commercial |
$10,885.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,401.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,410.35
|
| Rate for Payer: Cash Price |
$3,628.50
|
| Rate for Payer: Cigna Commercial |
$11,127.40
|
| Rate for Payer: Health EOS Commercial |
$10,764.55
|
| Rate for Payer: HFN Commercial |
$11,127.40
|
| Rate for Payer: Multiplan Commercial |
$9,676.00
|
| Rate for Payer: NAPHCARE Commercial |
$7,257.00
|
| Rate for Payer: Preferred Network Access Commercial |
$11,127.40
|
| Rate for Payer: Quartz Beloit One Network |
$5,926.55
|
| Rate for Payer: Quartz Commercial |
$7,257.00
|
| Rate for Payer: WEA Trust Commercial |
$6,652.25
|
| Rate for Payer: WPS Commercial |
$8,958.77
|
|
|
BRACHIOPLASTY/BRACHIAL PLEXUS SURGERY
|
Facility
|
OP
|
$12,095.00
|
|
| Hospital Charge Code |
2959871
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,386.60 |
| Max. Negotiated Rate |
$48,380.00 |
| Rate for Payer: Aetna Commercial |
$10,885.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,401.70
|
| Rate for Payer: Aetna Managed Medicare |
$3,386.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,861.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,047.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,805.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,410.35
|
| Rate for Payer: Cash Price |
$3,628.50
|
| Rate for Payer: Cigna Commercial |
$11,127.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,768.36
|
| Rate for Payer: Health EOS Commercial |
$10,764.55
|
| Rate for Payer: HFN Commercial |
$11,127.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,071.25
|
| Rate for Payer: Multiplan Commercial |
$9,676.00
|
| Rate for Payer: NAPHCARE Commercial |
$7,257.00
|
| Rate for Payer: Preferred Network Access Commercial |
$11,127.40
|
| Rate for Payer: Quartz Beloit One Network |
$5,926.55
|
| Rate for Payer: Quartz Commercial |
$7,861.75
|
| Rate for Payer: Quartz Medicare Advantage |
$7,257.00
|
| Rate for Payer: The Alliance Commercial |
$48,380.00
|
| Rate for Payer: WEA Trust Commercial |
$6,652.25
|
| Rate for Payer: WPS Commercial |
$8,958.77
|
|
