|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 9HL RT 02.112.046
|
Facility
|
IP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4340248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,361.89 |
| Max. Negotiated Rate |
$6,312.12 |
| Rate for Payer: Aetna Commercial |
$6,174.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,900.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,636.33
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,312.12
|
| Rate for Payer: Health EOS Commercial |
$6,106.29
|
| Rate for Payer: HFN Commercial |
$6,312.12
|
| Rate for Payer: Multiplan Commercial |
$5,488.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,116.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,312.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,361.89
|
| Rate for Payer: Quartz Commercial |
$4,116.60
|
| Rate for Payer: WEA Trust Commercial |
$3,773.55
|
| Rate for Payer: WPS Commercial |
$5,081.94
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 9HL RT 02.112.046
|
Facility
|
OP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4340248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,921.08 |
| Max. Negotiated Rate |
$27,444.00 |
| Rate for Payer: Aetna Commercial |
$6,174.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,900.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,921.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,459.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,293.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,636.33
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,312.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,839.42
|
| Rate for Payer: Health EOS Commercial |
$6,106.29
|
| Rate for Payer: HFN Commercial |
$6,312.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,145.75
|
| Rate for Payer: Multiplan Commercial |
$5,488.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,116.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,312.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,361.89
|
| Rate for Payer: Quartz Commercial |
$4,459.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,116.60
|
| Rate for Payer: The Alliance Commercial |
$27,444.00
|
| Rate for Payer: WEA Trust Commercial |
$3,773.55
|
| Rate for Payer: WPS Commercial |
$5,081.94
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 4HL RT 02.118.202
|
Facility
|
IP
|
$7,771.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4268743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,807.79 |
| Max. Negotiated Rate |
$7,149.32 |
| Rate for Payer: Aetna Commercial |
$6,993.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,683.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,118.63
|
| Rate for Payer: Cash Price |
$2,331.30
|
| Rate for Payer: Cigna Commercial |
$7,149.32
|
| Rate for Payer: Health EOS Commercial |
$6,916.19
|
| Rate for Payer: HFN Commercial |
$7,149.32
|
| Rate for Payer: Multiplan Commercial |
$6,216.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,662.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,149.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,807.79
|
| Rate for Payer: Quartz Commercial |
$4,662.60
|
| Rate for Payer: WEA Trust Commercial |
$4,274.05
|
| Rate for Payer: WPS Commercial |
$5,755.98
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 4HL RT 02.118.202
|
Facility
|
OP
|
$7,771.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4268743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,175.88 |
| Max. Negotiated Rate |
$31,084.00 |
| Rate for Payer: Aetna Commercial |
$6,993.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,683.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,175.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,051.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,885.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,730.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,118.63
|
| Rate for Payer: Cash Price |
$2,331.30
|
| Rate for Payer: Cigna Commercial |
$7,149.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,348.65
|
| Rate for Payer: Health EOS Commercial |
$6,916.19
|
| Rate for Payer: HFN Commercial |
$7,149.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,828.25
|
| Rate for Payer: Multiplan Commercial |
$6,216.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,662.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,149.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,807.79
|
| Rate for Payer: Quartz Commercial |
$5,051.15
|
| Rate for Payer: Quartz Medicare Advantage |
$4,662.60
|
| Rate for Payer: The Alliance Commercial |
$31,084.00
|
| Rate for Payer: WEA Trust Commercial |
$4,274.05
|
| Rate for Payer: WPS Commercial |
$5,755.98
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 6HL lT 02.118.205
|
Facility
|
OP
|
$7,789.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,180.92 |
| Max. Negotiated Rate |
$31,156.00 |
| Rate for Payer: Aetna Commercial |
$7,010.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,698.54
|
| Rate for Payer: Aetna Managed Medicare |
$2,180.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,062.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,894.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,738.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,128.17
|
| Rate for Payer: Cash Price |
$2,336.70
|
| Rate for Payer: Cigna Commercial |
$7,165.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,358.72
|
| Rate for Payer: Health EOS Commercial |
$6,932.21
|
| Rate for Payer: HFN Commercial |
$7,165.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,841.75
|
| Rate for Payer: Multiplan Commercial |
$6,231.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,673.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,165.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,816.61
|
| Rate for Payer: Quartz Commercial |
$5,062.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,673.40
|
| Rate for Payer: The Alliance Commercial |
$31,156.00
|
| Rate for Payer: WEA Trust Commercial |
$4,283.95
|
| Rate for Payer: WPS Commercial |
$5,769.31
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 6HL lT 02.118.205
|
Facility
|
IP
|
$7,789.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,816.61 |
| Max. Negotiated Rate |
$7,165.88 |
| Rate for Payer: Aetna Commercial |
$7,010.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,698.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,128.17
|
| Rate for Payer: Cash Price |
$2,336.70
|
| Rate for Payer: Cigna Commercial |
$7,165.88
|
| Rate for Payer: Health EOS Commercial |
$6,932.21
|
| Rate for Payer: HFN Commercial |
$7,165.88
|
| Rate for Payer: Multiplan Commercial |
$6,231.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,673.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,165.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,816.61
|
| Rate for Payer: Quartz Commercial |
$4,673.40
|
| Rate for Payer: WEA Trust Commercial |
$4,283.95
|
| Rate for Payer: WPS Commercial |
$5,769.31
|
|
|
PLATE 2.7 4HL LAT DIST FIBULA 02.112.139
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,734.32 |
| Max. Negotiated Rate |
$24,776.00 |
| Rate for Payer: Aetna Commercial |
$5,574.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,734.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,026.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,097.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,973.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,282.82
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,698.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,466.16
|
| Rate for Payer: Health EOS Commercial |
$5,512.66
|
| Rate for Payer: HFN Commercial |
$5,698.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,645.50
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,716.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,035.06
|
| Rate for Payer: Quartz Commercial |
$4,026.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,716.40
|
| Rate for Payer: The Alliance Commercial |
$24,776.00
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
PLATE 2.7 4HL LAT DIST FIBULA 02.112.139
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.06 |
| Max. Negotiated Rate |
$5,698.48 |
| Rate for Payer: Aetna Commercial |
$5,574.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,282.82
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,698.48
|
| Rate for Payer: Health EOS Commercial |
$5,512.66
|
| Rate for Payer: HFN Commercial |
$5,698.48
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,716.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,035.06
|
| Rate for Payer: Quartz Commercial |
$3,716.40
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
PLATE 2.7 LATERAL DISTAL FIBULA 5 HOLE LEFT 02.118.405
|
Facility
|
OP
|
$7,594.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3323490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,126.32 |
| Max. Negotiated Rate |
$30,376.00 |
| Rate for Payer: Aetna Commercial |
$6,834.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,530.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,126.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,936.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,797.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,645.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,024.82
|
| Rate for Payer: Cash Price |
$2,278.20
|
| Rate for Payer: Cigna Commercial |
$6,986.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,249.60
|
| Rate for Payer: Health EOS Commercial |
$6,758.66
|
| Rate for Payer: HFN Commercial |
$6,986.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,695.50
|
| Rate for Payer: Multiplan Commercial |
$6,075.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,556.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,986.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,721.06
|
| Rate for Payer: Quartz Commercial |
$4,936.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,556.40
|
| Rate for Payer: The Alliance Commercial |
$30,376.00
|
| Rate for Payer: WEA Trust Commercial |
$4,176.70
|
| Rate for Payer: WPS Commercial |
$5,624.88
|
|
|
PLATE 2.7 LATERAL DISTAL FIBULA 5 HOLE LEFT 02.118.405
|
Facility
|
IP
|
$7,594.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3323490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,721.06 |
| Max. Negotiated Rate |
$6,986.48 |
| Rate for Payer: Aetna Commercial |
$6,834.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,530.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,024.82
|
| Rate for Payer: Cash Price |
$2,278.20
|
| Rate for Payer: Cigna Commercial |
$6,986.48
|
| Rate for Payer: Health EOS Commercial |
$6,758.66
|
| Rate for Payer: HFN Commercial |
$6,986.48
|
| Rate for Payer: Multiplan Commercial |
$6,075.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,556.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,986.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,721.06
|
| Rate for Payer: Quartz Commercial |
$4,556.40
|
| Rate for Payer: WEA Trust Commercial |
$4,176.70
|
| Rate for Payer: WPS Commercial |
$5,624.88
|
|
|
PLATE 2.7 LCP 4HL 249.680
|
Facility
|
IP
|
$5,358.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,625.42 |
| Max. Negotiated Rate |
$4,929.36 |
| Rate for Payer: Aetna Commercial |
$4,822.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,607.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,839.74
|
| Rate for Payer: Cash Price |
$1,607.40
|
| Rate for Payer: Cigna Commercial |
$4,929.36
|
| Rate for Payer: Health EOS Commercial |
$4,768.62
|
| Rate for Payer: HFN Commercial |
$4,929.36
|
| Rate for Payer: Multiplan Commercial |
$4,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,214.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,929.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,625.42
|
| Rate for Payer: Quartz Commercial |
$3,214.80
|
| Rate for Payer: WEA Trust Commercial |
$2,946.90
|
| Rate for Payer: WPS Commercial |
$3,968.67
|
|
|
PLATE 2.7 LCP 4HL 249.680
|
Facility
|
OP
|
$5,358.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.24 |
| Max. Negotiated Rate |
$21,432.00 |
| Rate for Payer: Aetna Commercial |
$4,822.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,607.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,500.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,482.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,679.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,571.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,839.74
|
| Rate for Payer: Cash Price |
$1,607.40
|
| Rate for Payer: Cigna Commercial |
$4,929.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,998.34
|
| Rate for Payer: Health EOS Commercial |
$4,768.62
|
| Rate for Payer: HFN Commercial |
$4,929.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,018.50
|
| Rate for Payer: Multiplan Commercial |
$4,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,214.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,929.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,625.42
|
| Rate for Payer: Quartz Commercial |
$3,482.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,214.80
|
| Rate for Payer: The Alliance Commercial |
$21,432.00
|
| Rate for Payer: WEA Trust Commercial |
$2,946.90
|
| Rate for Payer: WPS Commercial |
$3,968.67
|
|
|
PLATE 2.7 LCP 7HL 249.683
|
Facility
|
OP
|
$3,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,097.88 |
| Max. Negotiated Rate |
$15,684.00 |
| Rate for Payer: Aetna Commercial |
$3,528.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,372.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,097.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,548.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,960.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,882.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,078.13
|
| Rate for Payer: Cash Price |
$1,176.30
|
| Rate for Payer: Cigna Commercial |
$3,607.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,194.19
|
| Rate for Payer: Health EOS Commercial |
$3,489.69
|
| Rate for Payer: HFN Commercial |
$3,607.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,940.75
|
| Rate for Payer: Multiplan Commercial |
$3,136.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,352.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,607.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,921.29
|
| Rate for Payer: Quartz Commercial |
$2,548.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,352.60
|
| Rate for Payer: The Alliance Commercial |
$15,684.00
|
| Rate for Payer: WEA Trust Commercial |
$2,156.55
|
| Rate for Payer: WPS Commercial |
$2,904.28
|
|
|
PLATE 2.7 LCP 7HL 249.683
|
Facility
|
IP
|
$3,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,921.29 |
| Max. Negotiated Rate |
$3,607.32 |
| Rate for Payer: Aetna Commercial |
$3,528.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,372.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,078.13
|
| Rate for Payer: Cash Price |
$1,176.30
|
| Rate for Payer: Cigna Commercial |
$3,607.32
|
| Rate for Payer: Health EOS Commercial |
$3,489.69
|
| Rate for Payer: HFN Commercial |
$3,607.32
|
| Rate for Payer: Multiplan Commercial |
$3,136.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,352.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,607.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,921.29
|
| Rate for Payer: Quartz Commercial |
$2,352.60
|
| Rate for Payer: WEA Trust Commercial |
$2,156.55
|
| Rate for Payer: WPS Commercial |
$2,904.28
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY 6 HOLE 02.111.900
|
Facility
|
IP
|
$5,201.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,548.49 |
| Max. Negotiated Rate |
$4,784.92 |
| Rate for Payer: Aetna Commercial |
$4,680.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,472.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,756.53
|
| Rate for Payer: Cash Price |
$1,560.30
|
| Rate for Payer: Cigna Commercial |
$4,784.92
|
| Rate for Payer: Health EOS Commercial |
$4,628.89
|
| Rate for Payer: HFN Commercial |
$4,784.92
|
| Rate for Payer: Multiplan Commercial |
$4,160.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,120.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,784.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,548.49
|
| Rate for Payer: Quartz Commercial |
$3,120.60
|
| Rate for Payer: WEA Trust Commercial |
$2,860.55
|
| Rate for Payer: WPS Commercial |
$3,852.38
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY 6 HOLE 02.111.900
|
Facility
|
OP
|
$5,201.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,456.28 |
| Max. Negotiated Rate |
$20,804.00 |
| Rate for Payer: Aetna Commercial |
$4,680.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,472.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,456.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,380.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,600.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,496.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,756.53
|
| Rate for Payer: Cash Price |
$1,560.30
|
| Rate for Payer: Cigna Commercial |
$4,784.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,910.48
|
| Rate for Payer: Health EOS Commercial |
$4,628.89
|
| Rate for Payer: HFN Commercial |
$4,784.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,900.75
|
| Rate for Payer: Multiplan Commercial |
$4,160.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,120.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,784.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,548.49
|
| Rate for Payer: Quartz Commercial |
$3,380.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,120.60
|
| Rate for Payer: The Alliance Commercial |
$20,804.00
|
| Rate for Payer: WEA Trust Commercial |
$2,860.55
|
| Rate for Payer: WPS Commercial |
$3,852.38
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY TI 6 HOLE 04.111.900
|
Facility
|
OP
|
$5,593.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,566.04 |
| Max. Negotiated Rate |
$22,372.00 |
| Rate for Payer: Aetna Commercial |
$5,033.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,809.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,566.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,796.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,684.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,964.29
|
| Rate for Payer: Cash Price |
$1,677.90
|
| Rate for Payer: Cigna Commercial |
$5,145.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,129.84
|
| Rate for Payer: Health EOS Commercial |
$4,977.77
|
| Rate for Payer: HFN Commercial |
$5,145.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,194.75
|
| Rate for Payer: Multiplan Commercial |
$4,474.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,355.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,145.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,740.57
|
| Rate for Payer: Quartz Commercial |
$3,635.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,355.80
|
| Rate for Payer: The Alliance Commercial |
$22,372.00
|
| Rate for Payer: WEA Trust Commercial |
$3,076.15
|
| Rate for Payer: WPS Commercial |
$4,142.74
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY TI 6 HOLE 04.111.900
|
Facility
|
IP
|
$5,593.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,740.57 |
| Max. Negotiated Rate |
$5,145.56 |
| Rate for Payer: Aetna Commercial |
$5,033.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,809.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,964.29
|
| Rate for Payer: Cash Price |
$1,677.90
|
| Rate for Payer: Cigna Commercial |
$5,145.56
|
| Rate for Payer: Health EOS Commercial |
$4,977.77
|
| Rate for Payer: HFN Commercial |
$5,145.56
|
| Rate for Payer: Multiplan Commercial |
$4,474.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,355.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,145.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,740.57
|
| Rate for Payer: Quartz Commercial |
$3,355.80
|
| Rate for Payer: WEA Trust Commercial |
$3,076.15
|
| Rate for Payer: WPS Commercial |
$4,142.74
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 3HL LT 02.118.401S
|
Facility
|
IP
|
$6,148.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5179147
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,012.52 |
| Max. Negotiated Rate |
$5,656.16 |
| Rate for Payer: Aetna Commercial |
$5,533.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,287.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,258.44
|
| Rate for Payer: Cash Price |
$1,844.40
|
| Rate for Payer: Cigna Commercial |
$5,656.16
|
| Rate for Payer: Health EOS Commercial |
$5,471.72
|
| Rate for Payer: HFN Commercial |
$5,656.16
|
| Rate for Payer: Multiplan Commercial |
$4,918.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,688.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,656.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,012.52
|
| Rate for Payer: Quartz Commercial |
$3,688.80
|
| Rate for Payer: WEA Trust Commercial |
$3,381.40
|
| Rate for Payer: WPS Commercial |
$4,553.82
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 3HL LT 02.118.401S
|
Facility
|
OP
|
$6,148.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5179147
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,721.44 |
| Max. Negotiated Rate |
$24,592.00 |
| Rate for Payer: Aetna Commercial |
$5,533.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,287.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,721.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,996.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,074.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,951.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,258.44
|
| Rate for Payer: Cash Price |
$1,844.40
|
| Rate for Payer: Cigna Commercial |
$5,656.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,440.42
|
| Rate for Payer: Health EOS Commercial |
$5,471.72
|
| Rate for Payer: HFN Commercial |
$5,656.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,611.00
|
| Rate for Payer: Multiplan Commercial |
$4,918.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,688.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,656.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,012.52
|
| Rate for Payer: Quartz Commercial |
$3,996.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,688.80
|
| Rate for Payer: The Alliance Commercial |
$24,592.00
|
| Rate for Payer: WEA Trust Commercial |
$3,381.40
|
| Rate for Payer: WPS Commercial |
$4,553.82
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 4HL RT 02.118.402
|
Facility
|
OP
|
$7,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,025.80 |
| Max. Negotiated Rate |
$28,940.00 |
| Rate for Payer: Aetna Commercial |
$6,511.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,222.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,025.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,702.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,617.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,472.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,834.55
|
| Rate for Payer: Cash Price |
$2,170.50
|
| Rate for Payer: Cigna Commercial |
$6,656.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,048.71
|
| Rate for Payer: Health EOS Commercial |
$6,439.15
|
| Rate for Payer: HFN Commercial |
$6,656.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,426.25
|
| Rate for Payer: Multiplan Commercial |
$5,788.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,341.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,656.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.15
|
| Rate for Payer: Quartz Commercial |
$4,702.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,341.00
|
| Rate for Payer: The Alliance Commercial |
$28,940.00
|
| Rate for Payer: WEA Trust Commercial |
$3,979.25
|
| Rate for Payer: WPS Commercial |
$5,358.96
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 4HL RT 02.118.402
|
Facility
|
IP
|
$7,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,545.15 |
| Max. Negotiated Rate |
$6,656.20 |
| Rate for Payer: Aetna Commercial |
$6,511.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,222.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,834.55
|
| Rate for Payer: Cash Price |
$2,170.50
|
| Rate for Payer: Cigna Commercial |
$6,656.20
|
| Rate for Payer: Health EOS Commercial |
$6,439.15
|
| Rate for Payer: HFN Commercial |
$6,656.20
|
| Rate for Payer: Multiplan Commercial |
$5,788.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,341.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,656.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.15
|
| Rate for Payer: Quartz Commercial |
$4,341.00
|
| Rate for Payer: WEA Trust Commercial |
$3,979.25
|
| Rate for Payer: WPS Commercial |
$5,358.96
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 6 HL LT 02.118.407
|
Facility
|
IP
|
$7,979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937359
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,909.71 |
| Max. Negotiated Rate |
$7,340.68 |
| Rate for Payer: Aetna Commercial |
$7,181.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.87
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,340.68
|
| Rate for Payer: Health EOS Commercial |
$7,101.31
|
| Rate for Payer: HFN Commercial |
$7,340.68
|
| Rate for Payer: Multiplan Commercial |
$6,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.71
|
| Rate for Payer: Quartz Commercial |
$4,787.40
|
| Rate for Payer: WEA Trust Commercial |
$4,388.45
|
| Rate for Payer: WPS Commercial |
$5,910.05
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 6 HL LT 02.118.407
|
Facility
|
OP
|
$7,979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937359
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,234.12 |
| Max. Negotiated Rate |
$31,916.00 |
| Rate for Payer: Aetna Commercial |
$7,181.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,234.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,186.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,989.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,829.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.87
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,340.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,465.05
|
| Rate for Payer: Health EOS Commercial |
$7,101.31
|
| Rate for Payer: HFN Commercial |
$7,340.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,984.25
|
| Rate for Payer: Multiplan Commercial |
$6,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.71
|
| Rate for Payer: Quartz Commercial |
$5,186.35
|
| Rate for Payer: Quartz Medicare Advantage |
$4,787.40
|
| Rate for Payer: The Alliance Commercial |
$31,916.00
|
| Rate for Payer: WEA Trust Commercial |
$4,388.45
|
| Rate for Payer: WPS Commercial |
$5,910.05
|
|
|
PLATE 2-COLUMN RT VOL DIST RAD 02.111.640
|
Facility
|
IP
|
$6,518.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,193.82 |
| Max. Negotiated Rate |
$5,996.56 |
| Rate for Payer: Aetna Commercial |
$5,866.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,605.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,454.54
|
| Rate for Payer: Cash Price |
$1,955.40
|
| Rate for Payer: Cigna Commercial |
$5,996.56
|
| Rate for Payer: Health EOS Commercial |
$5,801.02
|
| Rate for Payer: HFN Commercial |
$5,996.56
|
| Rate for Payer: Multiplan Commercial |
$5,214.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,910.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,996.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,193.82
|
| Rate for Payer: Quartz Commercial |
$3,910.80
|
| Rate for Payer: WEA Trust Commercial |
$3,584.90
|
| Rate for Payer: WPS Commercial |
$4,827.88
|
|
