Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
SPLINT ROLYAN EZEFORM THERMOPLASTIC MATERIAL WHITE -- A5771
Utica, NY
See all hospitals reporting HCPCS Q4051 →Price type
MVHS, Inc.’s median price of $215 is 944% above the median hospital's median price ($21), higher than 88% of the 308 hospitals reporting HCPCS Q4051. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 5 payers, 7 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | |||||||
|---|---|---|---|---|---|---|---|
| 1 | UnitedHealthcare uhc empire plan percent of total billed charges · bothfrom % of charges | $126 | $126 | — | — | — | $126 – $126 |
| 2 | Bcbs Ny excellus bcbs indemnity percent of total billed charges · bothfrom % of charges | $215 | $215 | — | — | — | $215 – $215 |
| 3 | Blue Cross Blue Shield excellus bcbs hmo/ppo percent of total billed charges · bothfrom % of charges | $215 | $215 | — | — | — | $215 – $215 |
| 4 | Excellus excellus bcbs hmo/ppo percent of total billed charges · bothfrom % of charges | $215 | $215 | — | — | — | $215 – $215 |
| 5 | Excellus excellus bcbs indemnity percent of total billed charges · bothfrom % of charges | $215 | $215 | — | — | — | $215 – $215 |
| 6 | UnitedHealthcare uhc commercial percent of total billed charges · bothfrom % of charges | $230 | $230 | — | — | — | $230 – $230 |
| 7 | Humana humana hmo/pos percent of total billed charges · bothfrom % of charges | $236 | $236 | — | — | — | $236 – $236 |
Last updated: Aug 7, 2026
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