|
PLATE 3.5 LC-DCP 12HL 223.62
|
Facility
|
IP
|
$1,660.00
|
|
| Hospital Charge Code |
2966700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$813.40 |
| Max. Negotiated Rate |
$1,527.20 |
| Rate for Payer: Aetna Commercial |
$1,494.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,427.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$879.80
|
| Rate for Payer: Cash Price |
$498.00
|
| Rate for Payer: Cigna Commercial |
$1,527.20
|
| Rate for Payer: Health EOS Commercial |
$1,477.40
|
| Rate for Payer: HFN Commercial |
$1,527.20
|
| Rate for Payer: Multiplan Commercial |
$1,328.00
|
| Rate for Payer: NAPHCARE Commercial |
$996.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,527.20
|
| Rate for Payer: Quartz Beloit One Network |
$813.40
|
| Rate for Payer: Quartz Commercial |
$996.00
|
| Rate for Payer: WEA Trust Commercial |
$913.00
|
| Rate for Payer: WPS Commercial |
$1,229.56
|
|
|
PLATE 3.5 LC-DCP 12HL 223.62
|
Facility
|
OP
|
$1,660.00
|
|
| Hospital Charge Code |
2966700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$464.80 |
| Max. Negotiated Rate |
$6,640.00 |
| Rate for Payer: Aetna Commercial |
$1,494.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,427.60
|
| Rate for Payer: Aetna Managed Medicare |
$464.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,079.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$830.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$796.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$879.80
|
| Rate for Payer: Cash Price |
$498.00
|
| Rate for Payer: Cigna Commercial |
$1,527.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$928.94
|
| Rate for Payer: Health EOS Commercial |
$1,477.40
|
| Rate for Payer: HFN Commercial |
$1,527.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,245.00
|
| Rate for Payer: Multiplan Commercial |
$1,328.00
|
| Rate for Payer: NAPHCARE Commercial |
$996.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,527.20
|
| Rate for Payer: Quartz Beloit One Network |
$813.40
|
| Rate for Payer: Quartz Commercial |
$1,079.00
|
| Rate for Payer: Quartz Medicare Advantage |
$996.00
|
| Rate for Payer: The Alliance Commercial |
$6,640.00
|
| Rate for Payer: WEA Trust Commercial |
$913.00
|
| Rate for Payer: WPS Commercial |
$1,229.56
|
|
|
PLATE 3.5 LC-DCP 5HL 223.55
|
Facility
|
IP
|
$1,529.00
|
|
| Hospital Charge Code |
2966701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$749.21 |
| Max. Negotiated Rate |
$1,406.68 |
| Rate for Payer: Aetna Commercial |
$1,376.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,314.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$810.37
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cigna Commercial |
$1,406.68
|
| Rate for Payer: Health EOS Commercial |
$1,360.81
|
| Rate for Payer: HFN Commercial |
$1,406.68
|
| Rate for Payer: Multiplan Commercial |
$1,223.20
|
| Rate for Payer: NAPHCARE Commercial |
$917.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,406.68
|
| Rate for Payer: Quartz Beloit One Network |
$749.21
|
| Rate for Payer: Quartz Commercial |
$917.40
|
| Rate for Payer: WEA Trust Commercial |
$840.95
|
| Rate for Payer: WPS Commercial |
$1,132.53
|
|
|
PLATE 3.5 LC-DCP 5HL 223.55
|
Facility
|
OP
|
$1,529.00
|
|
| Hospital Charge Code |
2966701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$428.12 |
| Max. Negotiated Rate |
$6,116.00 |
| Rate for Payer: Aetna Commercial |
$1,376.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,314.94
|
| Rate for Payer: Aetna Managed Medicare |
$428.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$993.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$764.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$733.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$810.37
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cigna Commercial |
$1,406.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$855.63
|
| Rate for Payer: Health EOS Commercial |
$1,360.81
|
| Rate for Payer: HFN Commercial |
$1,406.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,146.75
|
| Rate for Payer: Multiplan Commercial |
$1,223.20
|
| Rate for Payer: NAPHCARE Commercial |
$917.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,406.68
|
| Rate for Payer: Quartz Beloit One Network |
$749.21
|
| Rate for Payer: Quartz Commercial |
$993.85
|
| Rate for Payer: Quartz Medicare Advantage |
$917.40
|
| Rate for Payer: The Alliance Commercial |
$6,116.00
|
| Rate for Payer: WEA Trust Commercial |
$840.95
|
| Rate for Payer: WPS Commercial |
$1,132.53
|
|
|
PLATE 3.5 LC-DCP 6HL 223.56
|
Facility
|
IP
|
$1,968.00
|
|
| Hospital Charge Code |
2966621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$964.32 |
| Max. Negotiated Rate |
$1,810.56 |
| Rate for Payer: Aetna Commercial |
$1,771.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,692.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,043.04
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Cigna Commercial |
$1,810.56
|
| Rate for Payer: Health EOS Commercial |
$1,751.52
|
| Rate for Payer: HFN Commercial |
$1,810.56
|
| Rate for Payer: Multiplan Commercial |
$1,574.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,180.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,810.56
|
| Rate for Payer: Quartz Beloit One Network |
$964.32
|
| Rate for Payer: Quartz Commercial |
$1,180.80
|
| Rate for Payer: WEA Trust Commercial |
$1,082.40
|
| Rate for Payer: WPS Commercial |
$1,457.70
|
|
|
PLATE 3.5 LC-DCP 6HL 223.56
|
Facility
|
OP
|
$1,968.00
|
|
| Hospital Charge Code |
2966621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$551.04 |
| Max. Negotiated Rate |
$7,872.00 |
| Rate for Payer: Aetna Commercial |
$1,771.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,692.48
|
| Rate for Payer: Aetna Managed Medicare |
$551.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,279.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$984.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$944.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,043.04
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Cigna Commercial |
$1,810.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,101.29
|
| Rate for Payer: Health EOS Commercial |
$1,751.52
|
| Rate for Payer: HFN Commercial |
$1,810.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,476.00
|
| Rate for Payer: Multiplan Commercial |
$1,574.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,180.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,810.56
|
| Rate for Payer: Quartz Beloit One Network |
$964.32
|
| Rate for Payer: Quartz Commercial |
$1,279.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,180.80
|
| Rate for Payer: The Alliance Commercial |
$7,872.00
|
| Rate for Payer: WEA Trust Commercial |
$1,082.40
|
| Rate for Payer: WPS Commercial |
$1,457.70
|
|
|
PLATE 3.5 LC-DCP 7HL 223.57
|
Facility
|
OP
|
$1,862.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.36 |
| Max. Negotiated Rate |
$7,448.00 |
| Rate for Payer: Aetna Commercial |
$1,675.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,601.32
|
| Rate for Payer: Aetna Managed Medicare |
$521.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,210.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$931.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$893.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$986.86
|
| Rate for Payer: Cash Price |
$558.60
|
| Rate for Payer: Cigna Commercial |
$1,713.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,041.98
|
| Rate for Payer: Health EOS Commercial |
$1,657.18
|
| Rate for Payer: HFN Commercial |
$1,713.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,396.50
|
| Rate for Payer: Multiplan Commercial |
$1,489.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,117.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,713.04
|
| Rate for Payer: Quartz Beloit One Network |
$912.38
|
| Rate for Payer: Quartz Commercial |
$1,210.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,117.20
|
| Rate for Payer: The Alliance Commercial |
$7,448.00
|
| Rate for Payer: WEA Trust Commercial |
$1,024.10
|
| Rate for Payer: WPS Commercial |
$1,379.18
|
|
|
PLATE 3.5 LC-DCP 7HL 223.57
|
Facility
|
IP
|
$1,862.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$912.38 |
| Max. Negotiated Rate |
$1,713.04 |
| Rate for Payer: Aetna Commercial |
$1,675.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,601.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$986.86
|
| Rate for Payer: Cash Price |
$558.60
|
| Rate for Payer: Cigna Commercial |
$1,713.04
|
| Rate for Payer: Health EOS Commercial |
$1,657.18
|
| Rate for Payer: HFN Commercial |
$1,713.04
|
| Rate for Payer: Multiplan Commercial |
$1,489.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,117.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,713.04
|
| Rate for Payer: Quartz Beloit One Network |
$912.38
|
| Rate for Payer: Quartz Commercial |
$1,117.20
|
| Rate for Payer: WEA Trust Commercial |
$1,024.10
|
| Rate for Payer: WPS Commercial |
$1,379.18
|
|
|
PLATE 3.5 LC-DCP 8HL 223.58
|
Facility
|
OP
|
$1,726.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966622
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$483.28 |
| Max. Negotiated Rate |
$6,904.00 |
| Rate for Payer: Aetna Commercial |
$1,553.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,484.36
|
| Rate for Payer: Aetna Managed Medicare |
$483.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,121.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$863.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$828.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$914.78
|
| Rate for Payer: Cash Price |
$517.80
|
| Rate for Payer: Cigna Commercial |
$1,587.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$965.87
|
| Rate for Payer: Health EOS Commercial |
$1,536.14
|
| Rate for Payer: HFN Commercial |
$1,587.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,294.50
|
| Rate for Payer: Multiplan Commercial |
$1,380.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,035.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,587.92
|
| Rate for Payer: Quartz Beloit One Network |
$845.74
|
| Rate for Payer: Quartz Commercial |
$1,121.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,035.60
|
| Rate for Payer: The Alliance Commercial |
$6,904.00
|
| Rate for Payer: WEA Trust Commercial |
$949.30
|
| Rate for Payer: WPS Commercial |
$1,278.45
|
|
|
PLATE 3.5 LC-DCP 8HL 223.58
|
Facility
|
IP
|
$1,726.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966622
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.74 |
| Max. Negotiated Rate |
$1,587.92 |
| Rate for Payer: Aetna Commercial |
$1,553.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,484.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$914.78
|
| Rate for Payer: Cash Price |
$517.80
|
| Rate for Payer: Cigna Commercial |
$1,587.92
|
| Rate for Payer: Health EOS Commercial |
$1,536.14
|
| Rate for Payer: HFN Commercial |
$1,587.92
|
| Rate for Payer: Multiplan Commercial |
$1,380.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,035.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,587.92
|
| Rate for Payer: Quartz Beloit One Network |
$845.74
|
| Rate for Payer: Quartz Commercial |
$1,035.60
|
| Rate for Payer: WEA Trust Commercial |
$949.30
|
| Rate for Payer: WPS Commercial |
$1,278.45
|
|
|
PLATE 3.5 LCP MEDIAL/LATERAL ANTERIOR CLAVICLE 8HL 02.112.042S
|
Facility
|
IP
|
$6,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,030.16 |
| Max. Negotiated Rate |
$5,689.28 |
| Rate for Payer: Aetna Commercial |
$5,565.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,318.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,277.52
|
| Rate for Payer: Cash Price |
$1,855.20
|
| Rate for Payer: Cigna Commercial |
$5,689.28
|
| Rate for Payer: Health EOS Commercial |
$5,503.76
|
| Rate for Payer: HFN Commercial |
$5,689.28
|
| Rate for Payer: Multiplan Commercial |
$4,947.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,710.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,689.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,030.16
|
| Rate for Payer: Quartz Commercial |
$3,710.40
|
| Rate for Payer: WEA Trust Commercial |
$3,401.20
|
| Rate for Payer: WPS Commercial |
$4,580.49
|
|
|
PLATE 3.5 LCP MEDIAL/LATERAL ANTERIOR CLAVICLE 8HL 02.112.042S
|
Facility
|
OP
|
$6,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,731.52 |
| Max. Negotiated Rate |
$24,736.00 |
| Rate for Payer: Aetna Commercial |
$5,565.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,318.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,731.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,019.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,092.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,968.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,277.52
|
| Rate for Payer: Cash Price |
$1,855.20
|
| Rate for Payer: Cigna Commercial |
$5,689.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,460.57
|
| Rate for Payer: Health EOS Commercial |
$5,503.76
|
| Rate for Payer: HFN Commercial |
$5,689.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,638.00
|
| Rate for Payer: Multiplan Commercial |
$4,947.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,710.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,689.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,030.16
|
| Rate for Payer: Quartz Commercial |
$4,019.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,710.40
|
| Rate for Payer: The Alliance Commercial |
$24,736.00
|
| Rate for Payer: WEA Trust Commercial |
$3,401.20
|
| Rate for Payer: WPS Commercial |
$4,580.49
|
|
|
PLATE 3.5MM LCP MED/DISTAL TIBIA 10 HL LT 02.112.523
|
Facility
|
OP
|
$6,868.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4208662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,923.04 |
| Max. Negotiated Rate |
$27,472.00 |
| Rate for Payer: Aetna Commercial |
$6,181.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,906.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,923.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,464.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,434.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,296.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,640.04
|
| Rate for Payer: Cash Price |
$2,060.40
|
| Rate for Payer: Cigna Commercial |
$6,318.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,843.33
|
| Rate for Payer: Health EOS Commercial |
$6,112.52
|
| Rate for Payer: HFN Commercial |
$6,318.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,151.00
|
| Rate for Payer: Multiplan Commercial |
$5,494.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,318.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,365.32
|
| Rate for Payer: Quartz Commercial |
$4,464.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,120.80
|
| Rate for Payer: The Alliance Commercial |
$27,472.00
|
| Rate for Payer: WEA Trust Commercial |
$3,777.40
|
| Rate for Payer: WPS Commercial |
$5,087.13
|
|
|
PLATE 3.5MM LCP MED/DISTAL TIBIA 10 HL LT 02.112.523
|
Facility
|
IP
|
$6,868.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4208662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,365.32 |
| Max. Negotiated Rate |
$6,318.56 |
| Rate for Payer: Aetna Commercial |
$6,181.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,906.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,640.04
|
| Rate for Payer: Cash Price |
$2,060.40
|
| Rate for Payer: Cigna Commercial |
$6,318.56
|
| Rate for Payer: Health EOS Commercial |
$6,112.52
|
| Rate for Payer: HFN Commercial |
$6,318.56
|
| Rate for Payer: Multiplan Commercial |
$5,494.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,318.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,365.32
|
| Rate for Payer: Quartz Commercial |
$4,120.80
|
| Rate for Payer: WEA Trust Commercial |
$3,777.40
|
| Rate for Payer: WPS Commercial |
$5,087.13
|
|
|
PLATE 3.5MM LCP MED/DISTAL TIBIA 12 H LT 02.112.527
|
Facility
|
IP
|
$6,943.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4518751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,402.07 |
| Max. Negotiated Rate |
$6,387.56 |
| Rate for Payer: Aetna Commercial |
$6,248.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,970.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,679.79
|
| Rate for Payer: Cash Price |
$2,082.90
|
| Rate for Payer: Cigna Commercial |
$6,387.56
|
| Rate for Payer: Health EOS Commercial |
$6,179.27
|
| Rate for Payer: HFN Commercial |
$6,387.56
|
| Rate for Payer: Multiplan Commercial |
$5,554.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,165.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,387.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,402.07
|
| Rate for Payer: Quartz Commercial |
$4,165.80
|
| Rate for Payer: WEA Trust Commercial |
$3,818.65
|
| Rate for Payer: WPS Commercial |
$5,142.68
|
|
|
PLATE 3.5MM LCP MED/DISTAL TIBIA 12 H LT 02.112.527
|
Facility
|
OP
|
$6,943.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4518751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,944.04 |
| Max. Negotiated Rate |
$27,772.00 |
| Rate for Payer: Aetna Commercial |
$6,248.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,970.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,944.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,512.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,471.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,332.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,679.79
|
| Rate for Payer: Cash Price |
$2,082.90
|
| Rate for Payer: Cigna Commercial |
$6,387.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,885.30
|
| Rate for Payer: Health EOS Commercial |
$6,179.27
|
| Rate for Payer: HFN Commercial |
$6,387.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,207.25
|
| Rate for Payer: Multiplan Commercial |
$5,554.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,165.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,387.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,402.07
|
| Rate for Payer: Quartz Commercial |
$4,512.95
|
| Rate for Payer: Quartz Medicare Advantage |
$4,165.80
|
| Rate for Payer: The Alliance Commercial |
$27,772.00
|
| Rate for Payer: WEA Trust Commercial |
$3,818.65
|
| Rate for Payer: WPS Commercial |
$5,142.68
|
|
|
PLATE 3.5MM LCP SUPERIOR ANTERIOR CLAVICLE W LATERAL EXT 4HL LT 81MM 02.121.011S
|
Facility
|
OP
|
$6,203.00
|
|
| Hospital Charge Code |
2966336
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,736.84 |
| Max. Negotiated Rate |
$24,812.00 |
| Rate for Payer: Aetna Commercial |
$5,582.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,334.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,736.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,031.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,101.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,977.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.59
|
| Rate for Payer: Cash Price |
$1,860.90
|
| Rate for Payer: Cigna Commercial |
$5,706.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,471.20
|
| Rate for Payer: Health EOS Commercial |
$5,520.67
|
| Rate for Payer: HFN Commercial |
$5,706.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,652.25
|
| Rate for Payer: Multiplan Commercial |
$4,962.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,721.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,706.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.47
|
| Rate for Payer: Quartz Commercial |
$4,031.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,721.80
|
| Rate for Payer: The Alliance Commercial |
$24,812.00
|
| Rate for Payer: WEA Trust Commercial |
$3,411.65
|
| Rate for Payer: WPS Commercial |
$4,594.56
|
|
|
PLATE 3.5MM LCP SUPERIOR ANTERIOR CLAVICLE W LATERAL EXT 4HL LT 81MM 02.121.011S
|
Facility
|
IP
|
$6,203.00
|
|
| Hospital Charge Code |
2966336
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,039.47 |
| Max. Negotiated Rate |
$5,706.76 |
| Rate for Payer: Aetna Commercial |
$5,582.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,334.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.59
|
| Rate for Payer: Cash Price |
$1,860.90
|
| Rate for Payer: Cigna Commercial |
$5,706.76
|
| Rate for Payer: Health EOS Commercial |
$5,520.67
|
| Rate for Payer: HFN Commercial |
$5,706.76
|
| Rate for Payer: Multiplan Commercial |
$4,962.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,721.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,706.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.47
|
| Rate for Payer: Quartz Commercial |
$3,721.80
|
| Rate for Payer: WEA Trust Commercial |
$3,411.65
|
| Rate for Payer: WPS Commercial |
$4,594.56
|
|
|
PLATE 3.5MM METAPHYSEAL 11HOLE
|
Facility
|
OP
|
$6,283.00
|
|
| Hospital Charge Code |
2966342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,759.24 |
| Max. Negotiated Rate |
$25,132.00 |
| Rate for Payer: Aetna Commercial |
$5,654.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,403.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,759.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,083.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,141.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,015.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,329.99
|
| Rate for Payer: Cash Price |
$1,884.90
|
| Rate for Payer: Cigna Commercial |
$5,780.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,515.97
|
| Rate for Payer: Health EOS Commercial |
$5,591.87
|
| Rate for Payer: HFN Commercial |
$5,780.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,712.25
|
| Rate for Payer: Multiplan Commercial |
$5,026.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,769.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,780.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,078.67
|
| Rate for Payer: Quartz Commercial |
$4,083.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,769.80
|
| Rate for Payer: The Alliance Commercial |
$25,132.00
|
| Rate for Payer: WEA Trust Commercial |
$3,455.65
|
| Rate for Payer: WPS Commercial |
$4,653.82
|
|
|
PLATE 3.5MM METAPHYSEAL 11HOLE
|
Facility
|
IP
|
$6,283.00
|
|
| Hospital Charge Code |
2966342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,078.67 |
| Max. Negotiated Rate |
$5,780.36 |
| Rate for Payer: Aetna Commercial |
$5,654.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,403.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,329.99
|
| Rate for Payer: Cash Price |
$1,884.90
|
| Rate for Payer: Cigna Commercial |
$5,780.36
|
| Rate for Payer: Health EOS Commercial |
$5,591.87
|
| Rate for Payer: HFN Commercial |
$5,780.36
|
| Rate for Payer: Multiplan Commercial |
$5,026.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,769.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,780.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,078.67
|
| Rate for Payer: Quartz Commercial |
$3,769.80
|
| Rate for Payer: WEA Trust Commercial |
$3,455.65
|
| Rate for Payer: WPS Commercial |
$4,653.82
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 4HL LT 02.127.211
|
Facility
|
OP
|
$7,222.00
|
|
| Hospital Charge Code |
4462801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,022.16 |
| Max. Negotiated Rate |
$28,888.00 |
| Rate for Payer: Aetna Commercial |
$6,499.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,210.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,022.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,694.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,611.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,466.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,827.66
|
| Rate for Payer: Cash Price |
$2,166.60
|
| Rate for Payer: Cigna Commercial |
$6,644.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,041.43
|
| Rate for Payer: Health EOS Commercial |
$6,427.58
|
| Rate for Payer: HFN Commercial |
$6,644.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,416.50
|
| Rate for Payer: Multiplan Commercial |
$5,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,644.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.78
|
| Rate for Payer: Quartz Commercial |
$4,694.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,333.20
|
| Rate for Payer: The Alliance Commercial |
$28,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,972.10
|
| Rate for Payer: WPS Commercial |
$5,349.34
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 4HL LT 02.127.211
|
Facility
|
IP
|
$7,222.00
|
|
| Hospital Charge Code |
4462801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,538.78 |
| Max. Negotiated Rate |
$6,644.24 |
| Rate for Payer: Aetna Commercial |
$6,499.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,210.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,827.66
|
| Rate for Payer: Cash Price |
$2,166.60
|
| Rate for Payer: Cigna Commercial |
$6,644.24
|
| Rate for Payer: Health EOS Commercial |
$6,427.58
|
| Rate for Payer: HFN Commercial |
$6,644.24
|
| Rate for Payer: Multiplan Commercial |
$5,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,644.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.78
|
| Rate for Payer: Quartz Commercial |
$4,333.20
|
| Rate for Payer: WEA Trust Commercial |
$3,972.10
|
| Rate for Payer: WPS Commercial |
$5,349.34
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 4HL RT 02.127.210S
|
Facility
|
IP
|
$7,222.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5106922
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,538.78 |
| Max. Negotiated Rate |
$6,644.24 |
| Rate for Payer: Aetna Commercial |
$6,499.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,210.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,827.66
|
| Rate for Payer: Cash Price |
$2,166.60
|
| Rate for Payer: Cigna Commercial |
$6,644.24
|
| Rate for Payer: Health EOS Commercial |
$6,427.58
|
| Rate for Payer: HFN Commercial |
$6,644.24
|
| Rate for Payer: Multiplan Commercial |
$5,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,644.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.78
|
| Rate for Payer: Quartz Commercial |
$4,333.20
|
| Rate for Payer: WEA Trust Commercial |
$3,972.10
|
| Rate for Payer: WPS Commercial |
$5,349.34
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 4HL RT 02.127.210S
|
Facility
|
OP
|
$7,222.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5106922
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,022.16 |
| Max. Negotiated Rate |
$28,888.00 |
| Rate for Payer: Aetna Commercial |
$6,499.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,210.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,022.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,694.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,611.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,466.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,827.66
|
| Rate for Payer: Cash Price |
$2,166.60
|
| Rate for Payer: Cigna Commercial |
$6,644.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,041.43
|
| Rate for Payer: Health EOS Commercial |
$6,427.58
|
| Rate for Payer: HFN Commercial |
$6,644.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,416.50
|
| Rate for Payer: Multiplan Commercial |
$5,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,644.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.78
|
| Rate for Payer: Quartz Commercial |
$4,694.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,333.20
|
| Rate for Payer: The Alliance Commercial |
$28,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,972.10
|
| Rate for Payer: WPS Commercial |
$5,349.34
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 6HL LT 02.127.221S
|
Facility
|
OP
|
$7,533.00
|
|
| Hospital Charge Code |
5074826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,109.24 |
| Max. Negotiated Rate |
$30,132.00 |
| Rate for Payer: Aetna Commercial |
$6,779.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,478.38
|
| Rate for Payer: Aetna Managed Medicare |
$2,109.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,896.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,766.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,615.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,992.49
|
| Rate for Payer: Cash Price |
$2,259.90
|
| Rate for Payer: Cigna Commercial |
$6,930.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,215.47
|
| Rate for Payer: Health EOS Commercial |
$6,704.37
|
| Rate for Payer: HFN Commercial |
$6,930.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,649.75
|
| Rate for Payer: Multiplan Commercial |
$6,026.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,519.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,930.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,691.17
|
| Rate for Payer: Quartz Commercial |
$4,896.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,519.80
|
| Rate for Payer: The Alliance Commercial |
$30,132.00
|
| Rate for Payer: WEA Trust Commercial |
$4,143.15
|
| Rate for Payer: WPS Commercial |
$5,579.69
|
|
