|
CAST 4 BLUE SCOTCHCAST PLUS
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963580
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.37 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Aetna Managed Medicare |
$27.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.71
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.32
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: NAPHCARE Commercial |
$58.66
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$63.54
|
| Rate for Payer: Quartz Medicare Advantage |
$58.66
|
| Rate for Payer: The Alliance Commercial |
$48.88
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST 4 PINK SCOTCHCAST PLUS
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963605
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.37 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Aetna Managed Medicare |
$27.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.71
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.32
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: NAPHCARE Commercial |
$58.66
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$63.54
|
| Rate for Payer: Quartz Medicare Advantage |
$58.66
|
| Rate for Payer: The Alliance Commercial |
$48.88
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST 4 PINK SCOTCHCAST PLUS
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963605
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.90 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$58.66
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST 4 PURPLE SCOTCHCAST PLUS
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963606
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.90 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$58.66
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST 4 PURPLE SCOTCHCAST PLUS
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963606
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.37 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Aetna Managed Medicare |
$27.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.71
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.32
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: NAPHCARE Commercial |
$58.66
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$63.54
|
| Rate for Payer: Quartz Medicare Advantage |
$58.66
|
| Rate for Payer: The Alliance Commercial |
$48.88
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST 4 RED SCOTCHCAST PLUS
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963607
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.37 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Aetna Managed Medicare |
$27.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.71
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.32
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: NAPHCARE Commercial |
$58.66
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$63.54
|
| Rate for Payer: Quartz Medicare Advantage |
$58.66
|
| Rate for Payer: The Alliance Commercial |
$48.88
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST 4 RED SCOTCHCAST PLUS
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963607
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.90 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$58.66
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST APPLICATION OR REPLACEMENT
|
Facility
|
OP
|
$207.03
|
|
|
Service Code
|
EAPG 00039
|
| Min. Negotiated Rate |
$199.06 |
| Max. Negotiated Rate |
$207.03 |
| Rate for Payer: Anthem Medicaid |
$199.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$199.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$199.06
|
| Rate for Payer: Dean Health Medicaid |
$199.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$199.06
|
| Rate for Payer: Managed Health Services Medicaid |
$207.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.06
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$199.06
|
| Rate for Payer: United Healthcare Medicaid |
$199.06
|
|
|
CASTING ORTHO GLASS SPLINT 3X12 OG3PC
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
4422006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.10 |
| Max. Negotiated Rate |
$141.61 |
| Rate for Payer: Aetna Commercial |
$138.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Aetna Managed Medicare |
$43.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.14
|
| Rate for Payer: Health EOS Commercial |
$136.99
|
| Rate for Payer: HFN Commercial |
$141.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.44
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: NAPHCARE Commercial |
$92.35
|
| Rate for Payer: Preferred Network Access Commercial |
$141.61
|
| Rate for Payer: Quartz Beloit One Network |
$75.42
|
| Rate for Payer: Quartz Commercial |
$100.05
|
| Rate for Payer: Quartz Medicare Advantage |
$92.35
|
| Rate for Payer: The Alliance Commercial |
$76.96
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$114.00
|
|
|
CASTING ORTHO GLASS SPLINT 3X12 OG3PC
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
4422006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.42 |
| Max. Negotiated Rate |
$141.61 |
| Rate for Payer: Aetna Commercial |
$138.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Health EOS Commercial |
$136.99
|
| Rate for Payer: HFN Commercial |
$141.61
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: Preferred Network Access Commercial |
$141.61
|
| Rate for Payer: Quartz Beloit One Network |
$75.42
|
| Rate for Payer: Quartz Commercial |
$92.35
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$114.00
|
|
|
CAST PADDING 2 DELTA ROLLS 6242
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS A4580
|
| Hospital Charge Code |
2963599
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
CAST PADDING 2 DELTA ROLLS 6242
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS A4580
|
| Hospital Charge Code |
2963599
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
CAST SCOTCHCAST 3 WHITE
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963668
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.37 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Aetna Managed Medicare |
$27.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.71
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.32
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: NAPHCARE Commercial |
$58.66
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$63.54
|
| Rate for Payer: Quartz Medicare Advantage |
$58.66
|
| Rate for Payer: The Alliance Commercial |
$48.88
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST SCOTCHCAST 3 WHITE
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963668
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.90 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$58.66
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
CAST SCOTCHCAST 4 WHITE
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963608
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.82 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Aetna Managed Medicare |
$35.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.59
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.94
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: NAPHCARE Commercial |
$76.75
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$83.15
|
| Rate for Payer: Quartz Medicare Advantage |
$76.75
|
| Rate for Payer: The Alliance Commercial |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
CAST SCOTCHCAST 4 WHITE
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2963608
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$62.68 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$76.75
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
CAST SPECIALIST 2 X-FAST
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS A4580
|
| Hospital Charge Code |
2963948
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Aetna Managed Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.79
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$22.98
|
| Rate for Payer: Quartz Medicare Advantage |
$21.22
|
| Rate for Payer: The Alliance Commercial |
$17.68
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
CAST SPECIALIST 2 X-FAST
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS A4580
|
| Hospital Charge Code |
2963948
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$21.22
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
CAST SPECIALIST 6 X 5YRDS
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS A4580
|
| Hospital Charge Code |
2963735
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$34.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.84
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.60
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: Quartz Medicare Advantage |
$74.88
|
| Rate for Payer: The Alliance Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
CAST SPECIALIST 6 X 5YRDS
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS A4580
|
| Hospital Charge Code |
2963735
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$74.88
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
CAST/SPLINT ABOVE KNEE
|
Facility
|
IP
|
$1,731.00
|
|
| Hospital Charge Code |
3075858
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$882.12 |
| Max. Negotiated Rate |
$1,656.22 |
| Rate for Payer: Aetna Commercial |
$1,620.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,548.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.13
|
| Rate for Payer: Cash Price |
$519.30
|
| Rate for Payer: Cigna Commercial |
$1,656.22
|
| Rate for Payer: Health EOS Commercial |
$1,602.21
|
| Rate for Payer: HFN Commercial |
$1,656.22
|
| Rate for Payer: Multiplan Commercial |
$1,440.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,656.22
|
| Rate for Payer: Quartz Beloit One Network |
$882.12
|
| Rate for Payer: Quartz Commercial |
$1,080.14
|
| Rate for Payer: WEA Trust Commercial |
$990.13
|
| Rate for Payer: WPS Commercial |
$1,333.39
|
|
|
CAST/SPLINT ABOVE KNEE
|
Facility
|
OP
|
$1,731.00
|
|
| Hospital Charge Code |
3075858
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$504.07 |
| Max. Negotiated Rate |
$1,656.22 |
| Rate for Payer: Aetna Commercial |
$1,620.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,548.21
|
| Rate for Payer: Aetna Managed Medicare |
$504.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,170.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$900.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$864.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.13
|
| Rate for Payer: Cash Price |
$519.30
|
| Rate for Payer: Cigna Commercial |
$1,656.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,007.44
|
| Rate for Payer: Health EOS Commercial |
$1,602.21
|
| Rate for Payer: HFN Commercial |
$1,656.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,350.18
|
| Rate for Payer: Multiplan Commercial |
$1,440.19
|
| Rate for Payer: NAPHCARE Commercial |
$1,080.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,656.22
|
| Rate for Payer: Quartz Beloit One Network |
$882.12
|
| Rate for Payer: Quartz Commercial |
$1,170.16
|
| Rate for Payer: Quartz Medicare Advantage |
$1,080.14
|
| Rate for Payer: The Alliance Commercial |
$900.12
|
| Rate for Payer: WEA Trust Commercial |
$990.13
|
| Rate for Payer: WPS Commercial |
$1,333.39
|
|
|
CAST/SPLINT BELOW KNEE
|
Facility
|
IP
|
$1,323.00
|
|
| Hospital Charge Code |
3075859
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$674.20 |
| Max. Negotiated Rate |
$1,265.85 |
| Rate for Payer: Aetna Commercial |
$1,238.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,183.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$729.24
|
| Rate for Payer: Cash Price |
$396.90
|
| Rate for Payer: Cigna Commercial |
$1,265.85
|
| Rate for Payer: Health EOS Commercial |
$1,224.57
|
| Rate for Payer: HFN Commercial |
$1,265.85
|
| Rate for Payer: Multiplan Commercial |
$1,100.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,265.85
|
| Rate for Payer: Quartz Beloit One Network |
$674.20
|
| Rate for Payer: Quartz Commercial |
$825.55
|
| Rate for Payer: WEA Trust Commercial |
$756.76
|
| Rate for Payer: WPS Commercial |
$1,019.11
|
|
|
CAST/SPLINT BELOW KNEE
|
Facility
|
OP
|
$1,323.00
|
|
| Hospital Charge Code |
3075859
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$385.26 |
| Max. Negotiated Rate |
$1,265.85 |
| Rate for Payer: Aetna Commercial |
$1,238.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,183.29
|
| Rate for Payer: Aetna Managed Medicare |
$385.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$894.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$687.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$660.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$729.24
|
| Rate for Payer: Cash Price |
$396.90
|
| Rate for Payer: Cigna Commercial |
$1,265.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$769.99
|
| Rate for Payer: Health EOS Commercial |
$1,224.57
|
| Rate for Payer: HFN Commercial |
$1,265.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,031.94
|
| Rate for Payer: Multiplan Commercial |
$1,100.74
|
| Rate for Payer: NAPHCARE Commercial |
$825.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,265.85
|
| Rate for Payer: Quartz Beloit One Network |
$674.20
|
| Rate for Payer: Quartz Commercial |
$894.35
|
| Rate for Payer: Quartz Medicare Advantage |
$825.55
|
| Rate for Payer: The Alliance Commercial |
$687.96
|
| Rate for Payer: WEA Trust Commercial |
$756.76
|
| Rate for Payer: WPS Commercial |
$1,019.11
|
|
|
CAST/SPLINT LONG ARM
|
Facility
|
OP
|
$1,445.00
|
|
| Hospital Charge Code |
3075856
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$420.78 |
| Max. Negotiated Rate |
$1,382.58 |
| Rate for Payer: Aetna Commercial |
$1,352.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,292.41
|
| Rate for Payer: Aetna Managed Medicare |
$420.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$976.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$751.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$721.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$796.48
|
| Rate for Payer: Cash Price |
$433.50
|
| Rate for Payer: Cigna Commercial |
$1,382.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$840.99
|
| Rate for Payer: Health EOS Commercial |
$1,337.49
|
| Rate for Payer: HFN Commercial |
$1,382.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,127.10
|
| Rate for Payer: Multiplan Commercial |
$1,202.24
|
| Rate for Payer: NAPHCARE Commercial |
$901.68
|
| Rate for Payer: Preferred Network Access Commercial |
$1,382.58
|
| Rate for Payer: Quartz Beloit One Network |
$736.37
|
| Rate for Payer: Quartz Commercial |
$976.82
|
| Rate for Payer: Quartz Medicare Advantage |
$901.68
|
| Rate for Payer: The Alliance Commercial |
$751.40
|
| Rate for Payer: WEA Trust Commercial |
$826.54
|
| Rate for Payer: WPS Commercial |
$1,113.08
|
|
