|
PLATE 3HH/4HS L -20 442.512
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966715
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,259.44 |
| Max. Negotiated Rate |
$17,992.00 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,249.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,159.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,517.08
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,373.50
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,923.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.80
|
| Rate for Payer: The Alliance Commercial |
$17,992.00
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
PLATE 3HH/4HS L -20 442.512
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966715
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,204.02 |
| Max. Negotiated Rate |
$4,138.16 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,698.80
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
PLATE 3HH/4HS L +90 442.505
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,204.02 |
| Max. Negotiated Rate |
$4,138.16 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,698.80
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
PLATE 3HH/4HS L +90 442.505
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,259.44 |
| Max. Negotiated Rate |
$17,992.00 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,249.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,159.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,517.08
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,373.50
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,923.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.80
|
| Rate for Payer: The Alliance Commercial |
$17,992.00
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
PLATE 3HH/4HS L -90 442.507
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990949
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,204.02 |
| Max. Negotiated Rate |
$4,138.16 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,698.80
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
PLATE 3HH/4HS L -90 442.507
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990949
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,259.44 |
| Max. Negotiated Rate |
$17,992.00 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,249.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,159.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,517.08
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,373.50
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,923.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.80
|
| Rate for Payer: The Alliance Commercial |
$17,992.00
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
PLATE 4.5 CONDYLAR CRV 14HL RT 02.124.414S
|
Facility
|
IP
|
$8,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3181484
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,371.29 |
| Max. Negotiated Rate |
$8,207.32 |
| Rate for Payer: Aetna Commercial |
$8,028.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,672.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,728.13
|
| Rate for Payer: Cash Price |
$2,676.30
|
| Rate for Payer: Cigna Commercial |
$8,207.32
|
| Rate for Payer: Health EOS Commercial |
$7,939.69
|
| Rate for Payer: HFN Commercial |
$8,207.32
|
| Rate for Payer: Multiplan Commercial |
$7,136.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,352.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,207.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,371.29
|
| Rate for Payer: Quartz Commercial |
$5,352.60
|
| Rate for Payer: WEA Trust Commercial |
$4,906.55
|
| Rate for Payer: WPS Commercial |
$6,607.78
|
|
|
PLATE 4.5 CONDYLAR CRV 14HL RT 02.124.414S
|
Facility
|
OP
|
$8,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3181484
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,497.88 |
| Max. Negotiated Rate |
$35,684.00 |
| Rate for Payer: Aetna Commercial |
$8,028.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,672.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,497.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,798.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,460.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,282.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,728.13
|
| Rate for Payer: Cash Price |
$2,676.30
|
| Rate for Payer: Cigna Commercial |
$8,207.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,992.19
|
| Rate for Payer: Health EOS Commercial |
$7,939.69
|
| Rate for Payer: HFN Commercial |
$8,207.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,690.75
|
| Rate for Payer: Multiplan Commercial |
$7,136.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,352.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,207.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,371.29
|
| Rate for Payer: Quartz Commercial |
$5,798.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,352.60
|
| Rate for Payer: The Alliance Commercial |
$35,684.00
|
| Rate for Payer: WEA Trust Commercial |
$4,906.55
|
| Rate for Payer: WPS Commercial |
$6,607.78
|
|
|
PLATE 4.5MM VA CURVED CONDYLAR 02.124.416
|
Facility
|
OP
|
$9,088.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5799777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,544.64 |
| Max. Negotiated Rate |
$36,352.00 |
| Rate for Payer: Aetna Commercial |
$8,179.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,815.68
|
| Rate for Payer: Aetna Managed Medicare |
$2,544.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,907.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,544.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,362.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,816.64
|
| Rate for Payer: Cash Price |
$2,726.40
|
| Rate for Payer: Cigna Commercial |
$8,360.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,085.64
|
| Rate for Payer: Health EOS Commercial |
$8,088.32
|
| Rate for Payer: HFN Commercial |
$8,360.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,816.00
|
| Rate for Payer: Multiplan Commercial |
$7,270.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,452.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,360.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.12
|
| Rate for Payer: Quartz Commercial |
$5,907.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,452.80
|
| Rate for Payer: The Alliance Commercial |
$36,352.00
|
| Rate for Payer: WEA Trust Commercial |
$4,998.40
|
| Rate for Payer: WPS Commercial |
$6,731.48
|
|
|
PLATE 4.5MM VA CURVED CONDYLAR 02.124.416
|
Facility
|
IP
|
$9,088.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5799777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,453.12 |
| Max. Negotiated Rate |
$8,360.96 |
| Rate for Payer: Aetna Commercial |
$8,179.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,815.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,816.64
|
| Rate for Payer: Cash Price |
$2,726.40
|
| Rate for Payer: Cigna Commercial |
$8,360.96
|
| Rate for Payer: Health EOS Commercial |
$8,088.32
|
| Rate for Payer: HFN Commercial |
$8,360.96
|
| Rate for Payer: Multiplan Commercial |
$7,270.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,452.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,360.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.12
|
| Rate for Payer: Quartz Commercial |
$5,452.80
|
| Rate for Payer: WEA Trust Commercial |
$4,998.40
|
| Rate for Payer: WPS Commercial |
$6,731.48
|
|
|
PLATE 4.5 NARROW 14HL 224.641
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE 4.5 NARROW 14HL 224.641
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE 4.5 NARROW 16HL 224.661
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE 4.5 NARROW 16HL 224.661
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE 4.5 PROX FEMUR 6HL RT
|
Facility
|
IP
|
$9,274.00
|
|
| Hospital Charge Code |
2966346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,544.26 |
| Max. Negotiated Rate |
$8,532.08 |
| Rate for Payer: Aetna Commercial |
$8,346.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,975.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,915.22
|
| Rate for Payer: Cash Price |
$2,782.20
|
| Rate for Payer: Cigna Commercial |
$8,532.08
|
| Rate for Payer: Health EOS Commercial |
$8,253.86
|
| Rate for Payer: HFN Commercial |
$8,532.08
|
| Rate for Payer: Multiplan Commercial |
$7,419.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,564.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,532.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,544.26
|
| Rate for Payer: Quartz Commercial |
$5,564.40
|
| Rate for Payer: WEA Trust Commercial |
$5,100.70
|
| Rate for Payer: WPS Commercial |
$6,869.25
|
|
|
PLATE 4.5 PROX FEMUR 6HL RT
|
Facility
|
OP
|
$9,274.00
|
|
| Hospital Charge Code |
2966346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,596.72 |
| Max. Negotiated Rate |
$37,096.00 |
| Rate for Payer: Aetna Commercial |
$8,346.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,975.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,596.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,028.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,637.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,451.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,915.22
|
| Rate for Payer: Cash Price |
$2,782.20
|
| Rate for Payer: Cigna Commercial |
$8,532.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,189.73
|
| Rate for Payer: Health EOS Commercial |
$8,253.86
|
| Rate for Payer: HFN Commercial |
$8,532.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,955.50
|
| Rate for Payer: Multiplan Commercial |
$7,419.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,564.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,532.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,544.26
|
| Rate for Payer: Quartz Commercial |
$6,028.10
|
| Rate for Payer: Quartz Medicare Advantage |
$5,564.40
|
| Rate for Payer: The Alliance Commercial |
$37,096.00
|
| Rate for Payer: WEA Trust Commercial |
$5,100.70
|
| Rate for Payer: WPS Commercial |
$6,869.25
|
|
|
PLATE 4H 4H RT ANGLE T 241.141
|
Facility
|
OP
|
$1,379.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$386.12 |
| Max. Negotiated Rate |
$5,516.00 |
| Rate for Payer: Aetna Commercial |
$1,241.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,185.94
|
| Rate for Payer: Aetna Managed Medicare |
$386.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$896.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$661.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$730.87
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cigna Commercial |
$1,268.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$771.69
|
| Rate for Payer: Health EOS Commercial |
$1,227.31
|
| Rate for Payer: HFN Commercial |
$1,268.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,034.25
|
| Rate for Payer: Multiplan Commercial |
$1,103.20
|
| Rate for Payer: NAPHCARE Commercial |
$827.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,268.68
|
| Rate for Payer: Quartz Beloit One Network |
$675.71
|
| Rate for Payer: Quartz Commercial |
$896.35
|
| Rate for Payer: Quartz Medicare Advantage |
$827.40
|
| Rate for Payer: The Alliance Commercial |
$5,516.00
|
| Rate for Payer: WEA Trust Commercial |
$758.45
|
| Rate for Payer: WPS Commercial |
$1,021.43
|
|
|
PLATE 4H 4H RT ANGLE T 241.141
|
Facility
|
IP
|
$1,379.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$675.71 |
| Max. Negotiated Rate |
$1,268.68 |
| Rate for Payer: Aetna Commercial |
$1,241.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,185.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$730.87
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cigna Commercial |
$1,268.68
|
| Rate for Payer: Health EOS Commercial |
$1,227.31
|
| Rate for Payer: HFN Commercial |
$1,268.68
|
| Rate for Payer: Multiplan Commercial |
$1,103.20
|
| Rate for Payer: NAPHCARE Commercial |
$827.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,268.68
|
| Rate for Payer: Quartz Beloit One Network |
$675.71
|
| Rate for Payer: Quartz Commercial |
$827.40
|
| Rate for Payer: WEA Trust Commercial |
$758.45
|
| Rate for Payer: WPS Commercial |
$1,021.43
|
|
|
PLATE 4H 6H RT ANGLE T 241.161
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.80 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Aetna Commercial |
$648.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.60
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$662.40
|
| Rate for Payer: Health EOS Commercial |
$640.80
|
| Rate for Payer: HFN Commercial |
$662.40
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: NAPHCARE Commercial |
$432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$662.40
|
| Rate for Payer: Quartz Beloit One Network |
$352.80
|
| Rate for Payer: Quartz Commercial |
$432.00
|
| Rate for Payer: WEA Trust Commercial |
$396.00
|
| Rate for Payer: WPS Commercial |
$533.30
|
|
|
PLATE 4H 6H RT ANGLE T 241.161
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$201.60 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$648.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.20
|
| Rate for Payer: Aetna Managed Medicare |
$201.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$468.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$360.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$345.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.60
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$662.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$402.91
|
| Rate for Payer: Health EOS Commercial |
$640.80
|
| Rate for Payer: HFN Commercial |
$662.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$540.00
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: NAPHCARE Commercial |
$432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$662.40
|
| Rate for Payer: Quartz Beloit One Network |
$352.80
|
| Rate for Payer: Quartz Commercial |
$468.00
|
| Rate for Payer: Quartz Medicare Advantage |
$432.00
|
| Rate for Payer: The Alliance Commercial |
$2,880.00
|
| Rate for Payer: WEA Trust Commercial |
$396.00
|
| Rate for Payer: WPS Commercial |
$533.30
|
|
|
PLATE 4HL 3.5 RT M/D/T 239.900
|
Facility
|
OP
|
$7,307.00
|
|
| Hospital Charge Code |
2966725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,045.96 |
| Max. Negotiated Rate |
$29,228.00 |
| Rate for Payer: Aetna Commercial |
$6,576.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,284.02
|
| Rate for Payer: Aetna Managed Medicare |
$2,045.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,749.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,653.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,507.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,872.71
|
| Rate for Payer: Cash Price |
$2,192.10
|
| Rate for Payer: Cigna Commercial |
$6,722.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,089.00
|
| Rate for Payer: Health EOS Commercial |
$6,503.23
|
| Rate for Payer: HFN Commercial |
$6,722.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,480.25
|
| Rate for Payer: Multiplan Commercial |
$5,845.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,384.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,722.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,580.43
|
| Rate for Payer: Quartz Commercial |
$4,749.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,384.20
|
| Rate for Payer: The Alliance Commercial |
$29,228.00
|
| Rate for Payer: WEA Trust Commercial |
$4,018.85
|
| Rate for Payer: WPS Commercial |
$5,412.29
|
|
|
PLATE 4HL 3.5 RT M/D/T 239.900
|
Facility
|
IP
|
$7,307.00
|
|
| Hospital Charge Code |
2966725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,580.43 |
| Max. Negotiated Rate |
$6,722.44 |
| Rate for Payer: Aetna Commercial |
$6,576.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,284.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,872.71
|
| Rate for Payer: Cash Price |
$2,192.10
|
| Rate for Payer: Cigna Commercial |
$6,722.44
|
| Rate for Payer: Health EOS Commercial |
$6,503.23
|
| Rate for Payer: HFN Commercial |
$6,722.44
|
| Rate for Payer: Multiplan Commercial |
$5,845.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,384.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,722.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,580.43
|
| Rate for Payer: Quartz Commercial |
$4,384.20
|
| Rate for Payer: WEA Trust Commercial |
$4,018.85
|
| Rate for Payer: WPS Commercial |
$5,412.29
|
|
|
PLATE 4 HL/78MM DHS STANDARD
|
Facility
|
OP
|
$4,951.00
|
|
| Hospital Charge Code |
2966343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.28 |
| Max. Negotiated Rate |
$19,804.00 |
| Rate for Payer: Aetna Commercial |
$4,455.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,257.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,386.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,218.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,475.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,376.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,624.03
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,554.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,770.58
|
| Rate for Payer: Health EOS Commercial |
$4,406.39
|
| Rate for Payer: HFN Commercial |
$4,554.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,713.25
|
| Rate for Payer: Multiplan Commercial |
$3,960.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,970.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,554.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,425.99
|
| Rate for Payer: Quartz Commercial |
$3,218.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,970.60
|
| Rate for Payer: The Alliance Commercial |
$19,804.00
|
| Rate for Payer: WEA Trust Commercial |
$2,723.05
|
| Rate for Payer: WPS Commercial |
$3,667.21
|
|
|
PLATE 4 HL/78MM DHS STANDARD
|
Facility
|
IP
|
$4,951.00
|
|
| Hospital Charge Code |
2966343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,425.99 |
| Max. Negotiated Rate |
$4,554.92 |
| Rate for Payer: Aetna Commercial |
$4,455.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,257.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,624.03
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,554.92
|
| Rate for Payer: Health EOS Commercial |
$4,406.39
|
| Rate for Payer: HFN Commercial |
$4,554.92
|
| Rate for Payer: Multiplan Commercial |
$3,960.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,970.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,554.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,425.99
|
| Rate for Payer: Quartz Commercial |
$2,970.60
|
| Rate for Payer: WEA Trust Commercial |
$2,723.05
|
| Rate for Payer: WPS Commercial |
$3,667.21
|
|
|
PLATE 4HL/RT DISTAL FIBULA 02.112.138
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966348
|
|
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
|
|
