|
Plastic mod low ext pad/line L2275
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
HCPCS L2275
|
| Hospital Charge Code |
4524748
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$91.62 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$124.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$91.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.02
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.75
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$289.25
|
| Rate for Payer: Quartz Medicare Advantage |
$267.00
|
| Rate for Payer: The Alliance Commercial |
$1,780.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
Plastic mod low ext pad/line L2275
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
HCPCS L2275
|
| Hospital Charge Code |
4524748
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$218.05 |
| Max. Negotiated Rate |
$409.40 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, KELLY URETHRAL PLICATION)
|
Facility
|
OP
|
$19,665.00
|
|
|
Service Code
|
CPT 57220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$19,665.00 |
| Rate for Payer: Aetna Managed Medicare |
$4,916.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$4,916.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4,916.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4,916.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4,916.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4,916.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,288.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,916.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4,916.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4,916.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4,916.25
|
| Rate for Payer: NAPHCARE Commercial |
$7,374.38
|
| Rate for Payer: Quartz Medicare Advantage |
$4,916.25
|
| Rate for Payer: The Alliance Commercial |
$19,665.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,916.25
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: Wellcare Medicare |
$4,916.25
|
|
|
PLASTO FIX
|
Facility
|
IP
|
$675.00
|
|
| Hospital Charge Code |
2971519
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$330.75 |
| Max. Negotiated Rate |
$621.00 |
| Rate for Payer: Aetna Commercial |
$607.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$580.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$357.75
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$621.00
|
| Rate for Payer: Health EOS Commercial |
$600.75
|
| Rate for Payer: HFN Commercial |
$621.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: NAPHCARE Commercial |
$405.00
|
| Rate for Payer: Preferred Network Access Commercial |
$621.00
|
| Rate for Payer: Quartz Beloit One Network |
$330.75
|
| Rate for Payer: Quartz Commercial |
$405.00
|
| Rate for Payer: WEA Trust Commercial |
$371.25
|
| Rate for Payer: WPS Commercial |
$499.97
|
|
|
PLASTO FIX
|
Facility
|
OP
|
$675.00
|
|
| Hospital Charge Code |
2971519
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$2,700.00 |
| Rate for Payer: Aetna Commercial |
$607.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$580.50
|
| Rate for Payer: Aetna Managed Medicare |
$189.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$438.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$337.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$324.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$357.75
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$621.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$377.73
|
| Rate for Payer: Health EOS Commercial |
$600.75
|
| Rate for Payer: HFN Commercial |
$621.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$506.25
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: NAPHCARE Commercial |
$405.00
|
| Rate for Payer: Preferred Network Access Commercial |
$621.00
|
| Rate for Payer: Quartz Beloit One Network |
$330.75
|
| Rate for Payer: Quartz Commercial |
$438.75
|
| Rate for Payer: Quartz Medicare Advantage |
$405.00
|
| Rate for Payer: The Alliance Commercial |
$2,700.00
|
| Rate for Payer: WEA Trust Commercial |
$371.25
|
| Rate for Payer: WPS Commercial |
$499.97
|
|
|
PLATE 10H 3.5 LCP 223.601
|
Facility
|
OP
|
$1,623.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$454.44 |
| Max. Negotiated Rate |
$6,492.00 |
| Rate for Payer: Aetna Commercial |
$1,460.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,395.78
|
| Rate for Payer: Aetna Managed Medicare |
$454.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,054.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$811.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$779.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$860.19
|
| Rate for Payer: Cash Price |
$486.90
|
| Rate for Payer: Cigna Commercial |
$1,493.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$908.23
|
| Rate for Payer: Health EOS Commercial |
$1,444.47
|
| Rate for Payer: HFN Commercial |
$1,493.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,217.25
|
| Rate for Payer: Multiplan Commercial |
$1,298.40
|
| Rate for Payer: NAPHCARE Commercial |
$973.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,493.16
|
| Rate for Payer: Quartz Beloit One Network |
$795.27
|
| Rate for Payer: Quartz Commercial |
$1,054.95
|
| Rate for Payer: Quartz Medicare Advantage |
$973.80
|
| Rate for Payer: The Alliance Commercial |
$6,492.00
|
| Rate for Payer: WEA Trust Commercial |
$892.65
|
| Rate for Payer: WPS Commercial |
$1,202.16
|
|
|
PLATE 10H 3.5 LCP 223.601
|
Facility
|
IP
|
$1,623.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$795.27 |
| Max. Negotiated Rate |
$1,493.16 |
| Rate for Payer: Aetna Commercial |
$1,460.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,395.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$860.19
|
| Rate for Payer: Cash Price |
$486.90
|
| Rate for Payer: Cigna Commercial |
$1,493.16
|
| Rate for Payer: Health EOS Commercial |
$1,444.47
|
| Rate for Payer: HFN Commercial |
$1,493.16
|
| Rate for Payer: Multiplan Commercial |
$1,298.40
|
| Rate for Payer: NAPHCARE Commercial |
$973.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,493.16
|
| Rate for Payer: Quartz Beloit One Network |
$795.27
|
| Rate for Payer: Quartz Commercial |
$973.80
|
| Rate for Payer: WEA Trust Commercial |
$892.65
|
| Rate for Payer: WPS Commercial |
$1,202.16
|
|
|
PLATE 10H 3.5 LCP RECON 245.101
|
Facility
|
IP
|
$2,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,185.31 |
| Max. Negotiated Rate |
$2,225.48 |
| Rate for Payer: Aetna Commercial |
$2,177.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,080.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,282.07
|
| Rate for Payer: Cash Price |
$725.70
|
| Rate for Payer: Cigna Commercial |
$2,225.48
|
| Rate for Payer: Health EOS Commercial |
$2,152.91
|
| Rate for Payer: HFN Commercial |
$2,225.48
|
| Rate for Payer: Multiplan Commercial |
$1,935.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,451.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,225.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,185.31
|
| Rate for Payer: Quartz Commercial |
$1,451.40
|
| Rate for Payer: WEA Trust Commercial |
$1,330.45
|
| Rate for Payer: WPS Commercial |
$1,791.75
|
|
|
PLATE 10H 3.5 LCP RECON 245.101
|
Facility
|
OP
|
$2,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$677.32 |
| Max. Negotiated Rate |
$9,676.00 |
| Rate for Payer: Aetna Commercial |
$2,177.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,080.34
|
| Rate for Payer: Aetna Managed Medicare |
$677.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,572.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,209.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,161.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,282.07
|
| Rate for Payer: Cash Price |
$725.70
|
| Rate for Payer: Cigna Commercial |
$2,225.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,353.67
|
| Rate for Payer: Health EOS Commercial |
$2,152.91
|
| Rate for Payer: HFN Commercial |
$2,225.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,814.25
|
| Rate for Payer: Multiplan Commercial |
$1,935.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,451.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,225.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,185.31
|
| Rate for Payer: Quartz Commercial |
$1,572.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,451.40
|
| Rate for Payer: The Alliance Commercial |
$9,676.00
|
| Rate for Payer: WEA Trust Commercial |
$1,330.45
|
| Rate for Payer: WPS Commercial |
$1,791.75
|
|
|
PLATE 10 HL 1/3 COLLAR 121mm
|
Facility
|
OP
|
$5,386.00
|
|
| Hospital Charge Code |
2966317
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,508.08 |
| Max. Negotiated Rate |
$21,544.00 |
| Rate for Payer: Aetna Commercial |
$4,847.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,631.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,508.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,500.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,693.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,585.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,854.58
|
| Rate for Payer: Cash Price |
$1,615.80
|
| Rate for Payer: Cigna Commercial |
$4,955.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,014.01
|
| Rate for Payer: Health EOS Commercial |
$4,793.54
|
| Rate for Payer: HFN Commercial |
$4,955.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,039.50
|
| Rate for Payer: Multiplan Commercial |
$4,308.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,231.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,955.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,639.14
|
| Rate for Payer: Quartz Commercial |
$3,500.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,231.60
|
| Rate for Payer: The Alliance Commercial |
$21,544.00
|
| Rate for Payer: WEA Trust Commercial |
$2,962.30
|
| Rate for Payer: WPS Commercial |
$3,989.41
|
|
|
PLATE 10 HL 1/3 COLLAR 121mm
|
Facility
|
IP
|
$5,386.00
|
|
| Hospital Charge Code |
2966317
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,639.14 |
| Max. Negotiated Rate |
$4,955.12 |
| Rate for Payer: Aetna Commercial |
$4,847.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,631.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,854.58
|
| Rate for Payer: Cash Price |
$1,615.80
|
| Rate for Payer: Cigna Commercial |
$4,955.12
|
| Rate for Payer: Health EOS Commercial |
$4,793.54
|
| Rate for Payer: HFN Commercial |
$4,955.12
|
| Rate for Payer: Multiplan Commercial |
$4,308.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,231.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,955.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,639.14
|
| Rate for Payer: Quartz Commercial |
$3,231.60
|
| Rate for Payer: WEA Trust Commercial |
$2,962.30
|
| Rate for Payer: WPS Commercial |
$3,989.41
|
|
|
PLATE 10H LT CONDYLAR 222.661
|
Facility
|
IP
|
$4,678.00
|
|
| Hospital Charge Code |
2966664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,292.22 |
| Max. Negotiated Rate |
$4,303.76 |
| Rate for Payer: Aetna Commercial |
$4,210.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.34
|
| Rate for Payer: Cash Price |
$1,403.40
|
| Rate for Payer: Cigna Commercial |
$4,303.76
|
| Rate for Payer: Health EOS Commercial |
$4,163.42
|
| Rate for Payer: HFN Commercial |
$4,303.76
|
| Rate for Payer: Multiplan Commercial |
$3,742.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,806.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.22
|
| Rate for Payer: Quartz Commercial |
$2,806.80
|
| Rate for Payer: WEA Trust Commercial |
$2,572.90
|
| Rate for Payer: WPS Commercial |
$3,464.99
|
|
|
PLATE 10H LT CONDYLAR 222.661
|
Facility
|
OP
|
$4,678.00
|
|
| Hospital Charge Code |
2966664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,309.84 |
| Max. Negotiated Rate |
$18,712.00 |
| Rate for Payer: Aetna Commercial |
$4,210.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,309.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,040.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,339.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,245.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.34
|
| Rate for Payer: Cash Price |
$1,403.40
|
| Rate for Payer: Cigna Commercial |
$4,303.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,617.81
|
| Rate for Payer: Health EOS Commercial |
$4,163.42
|
| Rate for Payer: HFN Commercial |
$4,303.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,508.50
|
| Rate for Payer: Multiplan Commercial |
$3,742.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,806.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.22
|
| Rate for Payer: Quartz Commercial |
$3,040.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,806.80
|
| Rate for Payer: The Alliance Commercial |
$18,712.00
|
| Rate for Payer: WEA Trust Commercial |
$2,572.90
|
| Rate for Payer: WPS Commercial |
$3,464.99
|
|
|
PLATE 10H LT PROX/TIB 240.043
|
Facility
|
IP
|
$4,732.00
|
|
| Hospital Charge Code |
2966665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,318.68 |
| Max. Negotiated Rate |
$4,353.44 |
| Rate for Payer: Aetna Commercial |
$4,258.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,069.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,507.96
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,353.44
|
| Rate for Payer: Health EOS Commercial |
$4,211.48
|
| Rate for Payer: HFN Commercial |
$4,353.44
|
| Rate for Payer: Multiplan Commercial |
$3,785.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,839.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,353.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,318.68
|
| Rate for Payer: Quartz Commercial |
$2,839.20
|
| Rate for Payer: WEA Trust Commercial |
$2,602.60
|
| Rate for Payer: WPS Commercial |
$3,504.99
|
|
|
PLATE 10H LT PROX/TIB 240.043
|
Facility
|
OP
|
$4,732.00
|
|
| Hospital Charge Code |
2966665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,324.96 |
| Max. Negotiated Rate |
$18,928.00 |
| Rate for Payer: Aetna Commercial |
$4,258.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,069.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,324.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,075.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,366.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,271.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,507.96
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,353.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,648.03
|
| Rate for Payer: Health EOS Commercial |
$4,211.48
|
| Rate for Payer: HFN Commercial |
$4,353.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,549.00
|
| Rate for Payer: Multiplan Commercial |
$3,785.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,839.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,353.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,318.68
|
| Rate for Payer: Quartz Commercial |
$3,075.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,839.20
|
| Rate for Payer: The Alliance Commercial |
$18,928.00
|
| Rate for Payer: WEA Trust Commercial |
$2,602.60
|
| Rate for Payer: WPS Commercial |
$3,504.99
|
|
|
PLATE 10H RT CONDYLAR 222.660
|
Facility
|
IP
|
$4,678.00
|
|
| Hospital Charge Code |
2966666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,292.22 |
| Max. Negotiated Rate |
$4,303.76 |
| Rate for Payer: Aetna Commercial |
$4,210.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.34
|
| Rate for Payer: Cash Price |
$1,403.40
|
| Rate for Payer: Cigna Commercial |
$4,303.76
|
| Rate for Payer: Health EOS Commercial |
$4,163.42
|
| Rate for Payer: HFN Commercial |
$4,303.76
|
| Rate for Payer: Multiplan Commercial |
$3,742.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,806.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.22
|
| Rate for Payer: Quartz Commercial |
$2,806.80
|
| Rate for Payer: WEA Trust Commercial |
$2,572.90
|
| Rate for Payer: WPS Commercial |
$3,464.99
|
|
|
PLATE 10H RT CONDYLAR 222.660
|
Facility
|
OP
|
$4,678.00
|
|
| Hospital Charge Code |
2966666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,309.84 |
| Max. Negotiated Rate |
$18,712.00 |
| Rate for Payer: Aetna Commercial |
$4,210.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,309.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,040.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,339.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,245.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.34
|
| Rate for Payer: Cash Price |
$1,403.40
|
| Rate for Payer: Cigna Commercial |
$4,303.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,617.81
|
| Rate for Payer: Health EOS Commercial |
$4,163.42
|
| Rate for Payer: HFN Commercial |
$4,303.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,508.50
|
| Rate for Payer: Multiplan Commercial |
$3,742.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,806.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.22
|
| Rate for Payer: Quartz Commercial |
$3,040.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,806.80
|
| Rate for Payer: The Alliance Commercial |
$18,712.00
|
| Rate for Payer: WEA Trust Commercial |
$2,572.90
|
| Rate for Payer: WPS Commercial |
$3,464.99
|
|
|
PLATE 10H RT PROX/TIB 240.042
|
Facility
|
IP
|
$4,732.00
|
|
| Hospital Charge Code |
2966667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,318.68 |
| Max. Negotiated Rate |
$4,353.44 |
| Rate for Payer: Aetna Commercial |
$4,258.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,069.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,507.96
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,353.44
|
| Rate for Payer: Health EOS Commercial |
$4,211.48
|
| Rate for Payer: HFN Commercial |
$4,353.44
|
| Rate for Payer: Multiplan Commercial |
$3,785.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,839.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,353.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,318.68
|
| Rate for Payer: Quartz Commercial |
$2,839.20
|
| Rate for Payer: WEA Trust Commercial |
$2,602.60
|
| Rate for Payer: WPS Commercial |
$3,504.99
|
|
|
PLATE 10H RT PROX/TIB 240.042
|
Facility
|
OP
|
$4,732.00
|
|
| Hospital Charge Code |
2966667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,324.96 |
| Max. Negotiated Rate |
$18,928.00 |
| Rate for Payer: Aetna Commercial |
$4,258.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,069.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,324.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,075.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,366.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,271.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,507.96
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,353.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,648.03
|
| Rate for Payer: Health EOS Commercial |
$4,211.48
|
| Rate for Payer: HFN Commercial |
$4,353.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,549.00
|
| Rate for Payer: Multiplan Commercial |
$3,785.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,839.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,353.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,318.68
|
| Rate for Payer: Quartz Commercial |
$3,075.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,839.20
|
| Rate for Payer: The Alliance Commercial |
$18,928.00
|
| Rate for Payer: WEA Trust Commercial |
$2,602.60
|
| Rate for Payer: WPS Commercial |
$3,504.99
|
|
|
PLATE 12H 3.5 LCP 223.621
|
Facility
|
OP
|
$1,732.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$484.96 |
| Max. Negotiated Rate |
$6,928.00 |
| Rate for Payer: Aetna Commercial |
$1,558.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,489.52
|
| Rate for Payer: Aetna Managed Medicare |
$484.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,125.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$866.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$831.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$917.96
|
| Rate for Payer: Cash Price |
$519.60
|
| Rate for Payer: Cigna Commercial |
$1,593.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$969.23
|
| Rate for Payer: Health EOS Commercial |
$1,541.48
|
| Rate for Payer: HFN Commercial |
$1,593.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,299.00
|
| Rate for Payer: Multiplan Commercial |
$1,385.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,039.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,593.44
|
| Rate for Payer: Quartz Beloit One Network |
$848.68
|
| Rate for Payer: Quartz Commercial |
$1,125.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,039.20
|
| Rate for Payer: The Alliance Commercial |
$6,928.00
|
| Rate for Payer: WEA Trust Commercial |
$952.60
|
| Rate for Payer: WPS Commercial |
$1,282.89
|
|
|
PLATE 12H 3.5 LCP 223.621
|
Facility
|
IP
|
$1,732.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$848.68 |
| Max. Negotiated Rate |
$1,593.44 |
| Rate for Payer: Aetna Commercial |
$1,558.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,489.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$917.96
|
| Rate for Payer: Cash Price |
$519.60
|
| Rate for Payer: Cigna Commercial |
$1,593.44
|
| Rate for Payer: Health EOS Commercial |
$1,541.48
|
| Rate for Payer: HFN Commercial |
$1,593.44
|
| Rate for Payer: Multiplan Commercial |
$1,385.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,039.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,593.44
|
| Rate for Payer: Quartz Beloit One Network |
$848.68
|
| Rate for Payer: Quartz Commercial |
$1,039.20
|
| Rate for Payer: WEA Trust Commercial |
$952.60
|
| Rate for Payer: WPS Commercial |
$1,282.89
|
|
|
PLATE 12H 3.5 LCP RECO 245.121
|
Facility
|
IP
|
$2,641.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.09 |
| Max. Negotiated Rate |
$2,429.72 |
| Rate for Payer: Aetna Commercial |
$2,376.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,271.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,399.73
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,429.72
|
| Rate for Payer: Health EOS Commercial |
$2,350.49
|
| Rate for Payer: HFN Commercial |
$2,429.72
|
| Rate for Payer: Multiplan Commercial |
$2,112.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,584.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,429.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,294.09
|
| Rate for Payer: Quartz Commercial |
$1,584.60
|
| Rate for Payer: WEA Trust Commercial |
$1,452.55
|
| Rate for Payer: WPS Commercial |
$1,956.19
|
|
|
PLATE 12H 3.5 LCP RECO 245.121
|
Facility
|
OP
|
$2,641.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$739.48 |
| Max. Negotiated Rate |
$10,564.00 |
| Rate for Payer: Aetna Commercial |
$2,376.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,271.26
|
| Rate for Payer: Aetna Managed Medicare |
$739.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,716.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,320.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,267.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,399.73
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,429.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,477.90
|
| Rate for Payer: Health EOS Commercial |
$2,350.49
|
| Rate for Payer: HFN Commercial |
$2,429.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,980.75
|
| Rate for Payer: Multiplan Commercial |
$2,112.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,584.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,429.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,294.09
|
| Rate for Payer: Quartz Commercial |
$1,716.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,584.60
|
| Rate for Payer: The Alliance Commercial |
$10,564.00
|
| Rate for Payer: WEA Trust Commercial |
$1,452.55
|
| Rate for Payer: WPS Commercial |
$1,956.19
|
|
|
PLATE 12H LT CONDYLAR 222.663
|
Facility
|
IP
|
$4,449.00
|
|
| Hospital Charge Code |
2966671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,180.01 |
| Max. Negotiated Rate |
$4,093.08 |
| Rate for Payer: Aetna Commercial |
$4,004.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,826.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,357.97
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,093.08
|
| Rate for Payer: Health EOS Commercial |
$3,959.61
|
| Rate for Payer: HFN Commercial |
$4,093.08
|
| Rate for Payer: Multiplan Commercial |
$3,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,669.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,093.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,180.01
|
| Rate for Payer: Quartz Commercial |
$2,669.40
|
| Rate for Payer: WEA Trust Commercial |
$2,446.95
|
| Rate for Payer: WPS Commercial |
$3,295.37
|
|
|
PLATE 12H LT CONDYLAR 222.663
|
Facility
|
OP
|
$4,449.00
|
|
| Hospital Charge Code |
2966671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,245.72 |
| Max. Negotiated Rate |
$17,796.00 |
| Rate for Payer: Aetna Commercial |
$4,004.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,826.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,245.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,891.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,224.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,135.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,357.97
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,093.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,489.66
|
| Rate for Payer: Health EOS Commercial |
$3,959.61
|
| Rate for Payer: HFN Commercial |
$4,093.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,336.75
|
| Rate for Payer: Multiplan Commercial |
$3,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,669.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,093.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,180.01
|
| Rate for Payer: Quartz Commercial |
$2,891.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,669.40
|
| Rate for Payer: The Alliance Commercial |
$17,796.00
|
| Rate for Payer: WEA Trust Commercial |
$2,446.95
|
| Rate for Payer: WPS Commercial |
$3,295.37
|
|
