|
PLATE 1/3 TUBULAR 8HL 241.38
|
Facility
|
OP
|
$1,064.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$297.92 |
| Max. Negotiated Rate |
$4,256.00 |
| Rate for Payer: Aetna Commercial |
$957.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$915.04
|
| Rate for Payer: Aetna Managed Medicare |
$297.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$691.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$532.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$510.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$563.92
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: Cigna Commercial |
$978.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$595.41
|
| Rate for Payer: Health EOS Commercial |
$946.96
|
| Rate for Payer: HFN Commercial |
$978.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$798.00
|
| Rate for Payer: Multiplan Commercial |
$851.20
|
| Rate for Payer: NAPHCARE Commercial |
$638.40
|
| Rate for Payer: Preferred Network Access Commercial |
$978.88
|
| Rate for Payer: Quartz Beloit One Network |
$521.36
|
| Rate for Payer: Quartz Commercial |
$691.60
|
| Rate for Payer: Quartz Medicare Advantage |
$638.40
|
| Rate for Payer: The Alliance Commercial |
$4,256.00
|
| Rate for Payer: WEA Trust Commercial |
$585.20
|
| Rate for Payer: WPS Commercial |
$788.10
|
|
|
PLATE 1/3 TUBULAR 8HL 241.38
|
Facility
|
IP
|
$1,064.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.36 |
| Max. Negotiated Rate |
$978.88 |
| Rate for Payer: Aetna Commercial |
$957.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$915.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$563.92
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: Cigna Commercial |
$978.88
|
| Rate for Payer: Health EOS Commercial |
$946.96
|
| Rate for Payer: HFN Commercial |
$978.88
|
| Rate for Payer: Multiplan Commercial |
$851.20
|
| Rate for Payer: NAPHCARE Commercial |
$638.40
|
| Rate for Payer: Preferred Network Access Commercial |
$978.88
|
| Rate for Payer: Quartz Beloit One Network |
$521.36
|
| Rate for Payer: Quartz Commercial |
$638.40
|
| Rate for Payer: WEA Trust Commercial |
$585.20
|
| Rate for Payer: WPS Commercial |
$788.10
|
|
|
PLATE 1/3 TUBULAR 9HL 241.39
|
Facility
|
IP
|
$983.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5547452
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$481.67 |
| Max. Negotiated Rate |
$904.36 |
| Rate for Payer: Aetna Commercial |
$884.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$845.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$520.99
|
| Rate for Payer: Cash Price |
$294.90
|
| Rate for Payer: Cigna Commercial |
$904.36
|
| Rate for Payer: Health EOS Commercial |
$874.87
|
| Rate for Payer: HFN Commercial |
$904.36
|
| Rate for Payer: Multiplan Commercial |
$786.40
|
| Rate for Payer: NAPHCARE Commercial |
$589.80
|
| Rate for Payer: Preferred Network Access Commercial |
$904.36
|
| Rate for Payer: Quartz Beloit One Network |
$481.67
|
| Rate for Payer: Quartz Commercial |
$589.80
|
| Rate for Payer: WEA Trust Commercial |
$540.65
|
| Rate for Payer: WPS Commercial |
$728.11
|
|
|
PLATE 1/3 TUBULAR 9HL 241.39
|
Facility
|
OP
|
$983.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5547452
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$275.24 |
| Max. Negotiated Rate |
$3,932.00 |
| Rate for Payer: Aetna Commercial |
$884.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$845.38
|
| Rate for Payer: Aetna Managed Medicare |
$275.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$638.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$491.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$471.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$520.99
|
| Rate for Payer: Cash Price |
$294.90
|
| Rate for Payer: Cigna Commercial |
$904.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$550.09
|
| Rate for Payer: Health EOS Commercial |
$874.87
|
| Rate for Payer: HFN Commercial |
$904.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$737.25
|
| Rate for Payer: Multiplan Commercial |
$786.40
|
| Rate for Payer: NAPHCARE Commercial |
$589.80
|
| Rate for Payer: Preferred Network Access Commercial |
$904.36
|
| Rate for Payer: Quartz Beloit One Network |
$481.67
|
| Rate for Payer: Quartz Commercial |
$638.95
|
| Rate for Payer: Quartz Medicare Advantage |
$589.80
|
| Rate for Payer: The Alliance Commercial |
$3,932.00
|
| Rate for Payer: WEA Trust Commercial |
$540.65
|
| Rate for Payer: WPS Commercial |
$728.11
|
|
|
PLATE 14H 3.5 LCP 223.641
|
Facility
|
IP
|
$2,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,269.59 |
| Max. Negotiated Rate |
$2,383.72 |
| Rate for Payer: Aetna Commercial |
$2,331.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,228.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,373.23
|
| Rate for Payer: Cash Price |
$777.30
|
| Rate for Payer: Cigna Commercial |
$2,383.72
|
| Rate for Payer: Health EOS Commercial |
$2,305.99
|
| Rate for Payer: HFN Commercial |
$2,383.72
|
| Rate for Payer: Multiplan Commercial |
$2,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,554.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,383.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,269.59
|
| Rate for Payer: Quartz Commercial |
$1,554.60
|
| Rate for Payer: WEA Trust Commercial |
$1,425.05
|
| Rate for Payer: WPS Commercial |
$1,919.15
|
|
|
PLATE 14H 3.5 LCP 223.641
|
Facility
|
OP
|
$2,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$725.48 |
| Max. Negotiated Rate |
$10,364.00 |
| Rate for Payer: Aetna Commercial |
$2,331.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,228.26
|
| Rate for Payer: Aetna Managed Medicare |
$725.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,684.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,295.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,243.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,373.23
|
| Rate for Payer: Cash Price |
$777.30
|
| Rate for Payer: Cigna Commercial |
$2,383.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,449.92
|
| Rate for Payer: Health EOS Commercial |
$2,305.99
|
| Rate for Payer: HFN Commercial |
$2,383.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,943.25
|
| Rate for Payer: Multiplan Commercial |
$2,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,554.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,383.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,269.59
|
| Rate for Payer: Quartz Commercial |
$1,684.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,554.60
|
| Rate for Payer: The Alliance Commercial |
$10,364.00
|
| Rate for Payer: WEA Trust Commercial |
$1,425.05
|
| Rate for Payer: WPS Commercial |
$1,919.15
|
|
|
PLATE 14H LT CONDYLAR 222.665
|
Facility
|
IP
|
$4,836.00
|
|
| Hospital Charge Code |
2966676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,369.64 |
| Max. Negotiated Rate |
$4,449.12 |
| Rate for Payer: Aetna Commercial |
$4,352.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,158.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,563.08
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,449.12
|
| Rate for Payer: Health EOS Commercial |
$4,304.04
|
| Rate for Payer: HFN Commercial |
$4,449.12
|
| Rate for Payer: Multiplan Commercial |
$3,868.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,901.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,449.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,369.64
|
| Rate for Payer: Quartz Commercial |
$2,901.60
|
| Rate for Payer: WEA Trust Commercial |
$2,659.80
|
| Rate for Payer: WPS Commercial |
$3,582.03
|
|
|
PLATE 14H LT CONDYLAR 222.665
|
Facility
|
OP
|
$4,836.00
|
|
| Hospital Charge Code |
2966676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.08 |
| Max. Negotiated Rate |
$19,344.00 |
| Rate for Payer: Aetna Commercial |
$4,352.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,158.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,143.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,418.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,321.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,563.08
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,449.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,706.23
|
| Rate for Payer: Health EOS Commercial |
$4,304.04
|
| Rate for Payer: HFN Commercial |
$4,449.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,627.00
|
| Rate for Payer: Multiplan Commercial |
$3,868.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,901.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,449.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,369.64
|
| Rate for Payer: Quartz Commercial |
$3,143.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,901.60
|
| Rate for Payer: The Alliance Commercial |
$19,344.00
|
| Rate for Payer: WEA Trust Commercial |
$2,659.80
|
| Rate for Payer: WPS Commercial |
$3,582.03
|
|
|
PLATE 14H LT PROX/TIB 240.047
|
Facility
|
OP
|
$6,958.00
|
|
| Hospital Charge Code |
2966677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,948.24 |
| Max. Negotiated Rate |
$27,832.00 |
| Rate for Payer: Aetna Commercial |
$6,262.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,983.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,948.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,522.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,479.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,339.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,687.74
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,401.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,893.70
|
| Rate for Payer: Health EOS Commercial |
$6,192.62
|
| Rate for Payer: HFN Commercial |
$6,401.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,218.50
|
| Rate for Payer: Multiplan Commercial |
$5,566.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,174.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,401.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,409.42
|
| Rate for Payer: Quartz Commercial |
$4,522.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,174.80
|
| Rate for Payer: The Alliance Commercial |
$27,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,826.90
|
| Rate for Payer: WPS Commercial |
$5,153.79
|
|
|
PLATE 14H LT PROX/TIB 240.047
|
Facility
|
IP
|
$6,958.00
|
|
| Hospital Charge Code |
2966677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,409.42 |
| Max. Negotiated Rate |
$6,401.36 |
| Rate for Payer: Aetna Commercial |
$6,262.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,983.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,687.74
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,401.36
|
| Rate for Payer: Health EOS Commercial |
$6,192.62
|
| Rate for Payer: HFN Commercial |
$6,401.36
|
| Rate for Payer: Multiplan Commercial |
$5,566.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,174.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,401.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,409.42
|
| Rate for Payer: Quartz Commercial |
$4,174.80
|
| Rate for Payer: WEA Trust Commercial |
$3,826.90
|
| Rate for Payer: WPS Commercial |
$5,153.79
|
|
|
PLATE 14H RT CONDYLAR 222.664
|
Facility
|
IP
|
$4,836.00
|
|
| Hospital Charge Code |
2966675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,369.64 |
| Max. Negotiated Rate |
$4,449.12 |
| Rate for Payer: Aetna Commercial |
$4,352.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,158.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,563.08
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,449.12
|
| Rate for Payer: Health EOS Commercial |
$4,304.04
|
| Rate for Payer: HFN Commercial |
$4,449.12
|
| Rate for Payer: Multiplan Commercial |
$3,868.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,901.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,449.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,369.64
|
| Rate for Payer: Quartz Commercial |
$2,901.60
|
| Rate for Payer: WEA Trust Commercial |
$2,659.80
|
| Rate for Payer: WPS Commercial |
$3,582.03
|
|
|
PLATE 14H RT CONDYLAR 222.664
|
Facility
|
OP
|
$4,836.00
|
|
| Hospital Charge Code |
2966675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.08 |
| Max. Negotiated Rate |
$19,344.00 |
| Rate for Payer: Aetna Commercial |
$4,352.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,158.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,143.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,418.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,321.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,563.08
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,449.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,706.23
|
| Rate for Payer: Health EOS Commercial |
$4,304.04
|
| Rate for Payer: HFN Commercial |
$4,449.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,627.00
|
| Rate for Payer: Multiplan Commercial |
$3,868.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,901.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,449.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,369.64
|
| Rate for Payer: Quartz Commercial |
$3,143.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,901.60
|
| Rate for Payer: The Alliance Commercial |
$19,344.00
|
| Rate for Payer: WEA Trust Commercial |
$2,659.80
|
| Rate for Payer: WPS Commercial |
$3,582.03
|
|
|
PLATE 14H RT PROX/TIB 240.046
|
Facility
|
OP
|
$6,958.00
|
|
| Hospital Charge Code |
2966678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,948.24 |
| Max. Negotiated Rate |
$27,832.00 |
| Rate for Payer: Aetna Commercial |
$6,262.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,983.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,948.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,522.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,479.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,339.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,687.74
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,401.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,893.70
|
| Rate for Payer: Health EOS Commercial |
$6,192.62
|
| Rate for Payer: HFN Commercial |
$6,401.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,218.50
|
| Rate for Payer: Multiplan Commercial |
$5,566.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,174.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,401.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,409.42
|
| Rate for Payer: Quartz Commercial |
$4,522.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,174.80
|
| Rate for Payer: The Alliance Commercial |
$27,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,826.90
|
| Rate for Payer: WPS Commercial |
$5,153.79
|
|
|
PLATE 14H RT PROX/TIB 240.046
|
Facility
|
IP
|
$6,958.00
|
|
| Hospital Charge Code |
2966678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,409.42 |
| Max. Negotiated Rate |
$6,401.36 |
| Rate for Payer: Aetna Commercial |
$6,262.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,983.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,687.74
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,401.36
|
| Rate for Payer: Health EOS Commercial |
$6,192.62
|
| Rate for Payer: HFN Commercial |
$6,401.36
|
| Rate for Payer: Multiplan Commercial |
$5,566.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,174.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,401.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,409.42
|
| Rate for Payer: Quartz Commercial |
$4,174.80
|
| Rate for Payer: WEA Trust Commercial |
$3,826.90
|
| Rate for Payer: WPS Commercial |
$5,153.79
|
|
|
PLATE 1/4 TUBULAR 3HL 242.03
|
Facility
|
OP
|
$434.00
|
|
| Hospital Charge Code |
2966656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$121.52 |
| Max. Negotiated Rate |
$1,736.00 |
| Rate for Payer: Aetna Commercial |
$390.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Aetna Managed Medicare |
$121.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$282.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$217.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$208.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.02
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$399.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$242.87
|
| Rate for Payer: Health EOS Commercial |
$386.26
|
| Rate for Payer: HFN Commercial |
$399.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$325.50
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: NAPHCARE Commercial |
$260.40
|
| Rate for Payer: Preferred Network Access Commercial |
$399.28
|
| Rate for Payer: Quartz Beloit One Network |
$212.66
|
| Rate for Payer: Quartz Commercial |
$282.10
|
| Rate for Payer: Quartz Medicare Advantage |
$260.40
|
| Rate for Payer: The Alliance Commercial |
$1,736.00
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: WPS Commercial |
$321.46
|
|
|
PLATE 1/4 TUBULAR 3HL 242.03
|
Facility
|
IP
|
$434.00
|
|
| Hospital Charge Code |
2966656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$212.66 |
| Max. Negotiated Rate |
$399.28 |
| Rate for Payer: Aetna Commercial |
$390.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.02
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$399.28
|
| Rate for Payer: Health EOS Commercial |
$386.26
|
| Rate for Payer: HFN Commercial |
$399.28
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: NAPHCARE Commercial |
$260.40
|
| Rate for Payer: Preferred Network Access Commercial |
$399.28
|
| Rate for Payer: Quartz Beloit One Network |
$212.66
|
| Rate for Payer: Quartz Commercial |
$260.40
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: WPS Commercial |
$321.46
|
|
|
PLATE 1/4 TUBULAR 4HL 242.04
|
Facility
|
IP
|
$978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$479.22 |
| Max. Negotiated Rate |
$899.76 |
| Rate for Payer: Aetna Commercial |
$880.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$841.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.34
|
| Rate for Payer: Cash Price |
$293.40
|
| Rate for Payer: Cigna Commercial |
$899.76
|
| Rate for Payer: Health EOS Commercial |
$870.42
|
| Rate for Payer: HFN Commercial |
$899.76
|
| Rate for Payer: Multiplan Commercial |
$782.40
|
| Rate for Payer: NAPHCARE Commercial |
$586.80
|
| Rate for Payer: Preferred Network Access Commercial |
$899.76
|
| Rate for Payer: Quartz Beloit One Network |
$479.22
|
| Rate for Payer: Quartz Commercial |
$586.80
|
| Rate for Payer: WEA Trust Commercial |
$537.90
|
| Rate for Payer: WPS Commercial |
$724.40
|
|
|
PLATE 1/4 TUBULAR 4HL 242.04
|
Facility
|
OP
|
$978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$273.84 |
| Max. Negotiated Rate |
$3,912.00 |
| Rate for Payer: Aetna Commercial |
$880.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$841.08
|
| Rate for Payer: Aetna Managed Medicare |
$273.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$635.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$469.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.34
|
| Rate for Payer: Cash Price |
$293.40
|
| Rate for Payer: Cigna Commercial |
$899.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.29
|
| Rate for Payer: Health EOS Commercial |
$870.42
|
| Rate for Payer: HFN Commercial |
$899.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$733.50
|
| Rate for Payer: Multiplan Commercial |
$782.40
|
| Rate for Payer: NAPHCARE Commercial |
$586.80
|
| Rate for Payer: Preferred Network Access Commercial |
$899.76
|
| Rate for Payer: Quartz Beloit One Network |
$479.22
|
| Rate for Payer: Quartz Commercial |
$635.70
|
| Rate for Payer: Quartz Medicare Advantage |
$586.80
|
| Rate for Payer: The Alliance Commercial |
$3,912.00
|
| Rate for Payer: WEA Trust Commercial |
$537.90
|
| Rate for Payer: WPS Commercial |
$724.40
|
|
|
PLATE 1/4 TUBULAR 5HL 242.05
|
Facility
|
OP
|
$547.00
|
|
| Hospital Charge Code |
2966658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$153.16 |
| Max. Negotiated Rate |
$2,188.00 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Aetna Managed Medicare |
$153.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$355.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$262.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.10
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$410.25
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$355.55
|
| Rate for Payer: Quartz Medicare Advantage |
$328.20
|
| Rate for Payer: The Alliance Commercial |
$2,188.00
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
PLATE 1/4 TUBULAR 5HL 242.05
|
Facility
|
IP
|
$547.00
|
|
| Hospital Charge Code |
2966658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$268.03 |
| Max. Negotiated Rate |
$503.24 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$328.20
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
PLATE 1/4 TUBULAR 6HL 242.06
|
Facility
|
OP
|
$1,145.00
|
|
| Hospital Charge Code |
2966659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$320.60 |
| Max. Negotiated Rate |
$4,580.00 |
| Rate for Payer: Aetna Commercial |
$1,030.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$984.70
|
| Rate for Payer: Aetna Managed Medicare |
$320.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$744.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$572.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$549.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$606.85
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$1,053.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$640.74
|
| Rate for Payer: Health EOS Commercial |
$1,019.05
|
| Rate for Payer: HFN Commercial |
$1,053.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$858.75
|
| Rate for Payer: Multiplan Commercial |
$916.00
|
| Rate for Payer: NAPHCARE Commercial |
$687.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,053.40
|
| Rate for Payer: Quartz Beloit One Network |
$561.05
|
| Rate for Payer: Quartz Commercial |
$744.25
|
| Rate for Payer: Quartz Medicare Advantage |
$687.00
|
| Rate for Payer: The Alliance Commercial |
$4,580.00
|
| Rate for Payer: WEA Trust Commercial |
$629.75
|
| Rate for Payer: WPS Commercial |
$848.10
|
|
|
PLATE 1/4 TUBULAR 6HL 242.06
|
Facility
|
IP
|
$1,145.00
|
|
| Hospital Charge Code |
2966659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.05 |
| Max. Negotiated Rate |
$1,053.40 |
| Rate for Payer: Aetna Commercial |
$1,030.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$984.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$606.85
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$1,053.40
|
| Rate for Payer: Health EOS Commercial |
$1,019.05
|
| Rate for Payer: HFN Commercial |
$1,053.40
|
| Rate for Payer: Multiplan Commercial |
$916.00
|
| Rate for Payer: NAPHCARE Commercial |
$687.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,053.40
|
| Rate for Payer: Quartz Beloit One Network |
$561.05
|
| Rate for Payer: Quartz Commercial |
$687.00
|
| Rate for Payer: WEA Trust Commercial |
$629.75
|
| Rate for Payer: WPS Commercial |
$848.10
|
|
|
PLATE 1/4 TUBULAR 7HL 242.07
|
Facility
|
IP
|
$627.00
|
|
| Hospital Charge Code |
2966660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$307.23 |
| Max. Negotiated Rate |
$576.84 |
| Rate for Payer: Aetna Commercial |
$564.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$539.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$332.31
|
| Rate for Payer: Cash Price |
$188.10
|
| Rate for Payer: Cigna Commercial |
$576.84
|
| Rate for Payer: Health EOS Commercial |
$558.03
|
| Rate for Payer: HFN Commercial |
$576.84
|
| Rate for Payer: Multiplan Commercial |
$501.60
|
| Rate for Payer: NAPHCARE Commercial |
$376.20
|
| Rate for Payer: Preferred Network Access Commercial |
$576.84
|
| Rate for Payer: Quartz Beloit One Network |
$307.23
|
| Rate for Payer: Quartz Commercial |
$376.20
|
| Rate for Payer: WEA Trust Commercial |
$344.85
|
| Rate for Payer: WPS Commercial |
$464.42
|
|
|
PLATE 1/4 TUBULAR 7HL 242.07
|
Facility
|
OP
|
$627.00
|
|
| Hospital Charge Code |
2966660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.56 |
| Max. Negotiated Rate |
$2,508.00 |
| Rate for Payer: Aetna Commercial |
$564.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$539.22
|
| Rate for Payer: Aetna Managed Medicare |
$175.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$313.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$300.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$332.31
|
| Rate for Payer: Cash Price |
$188.10
|
| Rate for Payer: Cigna Commercial |
$576.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$350.87
|
| Rate for Payer: Health EOS Commercial |
$558.03
|
| Rate for Payer: HFN Commercial |
$576.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$470.25
|
| Rate for Payer: Multiplan Commercial |
$501.60
|
| Rate for Payer: NAPHCARE Commercial |
$376.20
|
| Rate for Payer: Preferred Network Access Commercial |
$576.84
|
| Rate for Payer: Quartz Beloit One Network |
$307.23
|
| Rate for Payer: Quartz Commercial |
$407.55
|
| Rate for Payer: Quartz Medicare Advantage |
$376.20
|
| Rate for Payer: The Alliance Commercial |
$2,508.00
|
| Rate for Payer: WEA Trust Commercial |
$344.85
|
| Rate for Payer: WPS Commercial |
$464.42
|
|
|
PLATE 1/4 TUBULAR 8HL 242.08
|
Facility
|
IP
|
$1,776.00
|
|
| Hospital Charge Code |
2966661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$870.24 |
| Max. Negotiated Rate |
$1,633.92 |
| Rate for Payer: Aetna Commercial |
$1,598.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.28
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: Cigna Commercial |
$1,633.92
|
| Rate for Payer: Health EOS Commercial |
$1,580.64
|
| Rate for Payer: HFN Commercial |
$1,633.92
|
| Rate for Payer: Multiplan Commercial |
$1,420.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,633.92
|
| Rate for Payer: Quartz Beloit One Network |
$870.24
|
| Rate for Payer: Quartz Commercial |
$1,065.60
|
| Rate for Payer: WEA Trust Commercial |
$976.80
|
| Rate for Payer: WPS Commercial |
$1,315.48
|
|
