|
PLATE DISTAL FIBULA LATERAL 2.7 5HL RT 02.118.404
|
Facility
|
IP
|
$8,478.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3444847
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,154.22 |
| Max. Negotiated Rate |
$7,799.76 |
| Rate for Payer: Aetna Commercial |
$7,630.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,291.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,493.34
|
| Rate for Payer: Cash Price |
$2,543.40
|
| Rate for Payer: Cigna Commercial |
$7,799.76
|
| Rate for Payer: Health EOS Commercial |
$7,545.42
|
| Rate for Payer: HFN Commercial |
$7,799.76
|
| Rate for Payer: Multiplan Commercial |
$6,782.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,086.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,799.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,154.22
|
| Rate for Payer: Quartz Commercial |
$5,086.80
|
| Rate for Payer: WEA Trust Commercial |
$4,662.90
|
| Rate for Payer: WPS Commercial |
$6,279.65
|
|
|
PLATE DISTAL FIBULA LATERAL 3HL 40-20903
|
Facility
|
OP
|
$4,216.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415586
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,180.48 |
| Max. Negotiated Rate |
$16,864.00 |
| Rate for Payer: Aetna Commercial |
$3,794.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,625.76
|
| Rate for Payer: Aetna Managed Medicare |
$1,180.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,740.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,108.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,023.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,234.48
|
| Rate for Payer: Cash Price |
$1,264.80
|
| Rate for Payer: Cigna Commercial |
$3,878.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,359.27
|
| Rate for Payer: Health EOS Commercial |
$3,752.24
|
| Rate for Payer: HFN Commercial |
$3,878.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,162.00
|
| Rate for Payer: Multiplan Commercial |
$3,372.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,529.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,878.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,065.84
|
| Rate for Payer: Quartz Commercial |
$2,740.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,529.60
|
| Rate for Payer: The Alliance Commercial |
$16,864.00
|
| Rate for Payer: WEA Trust Commercial |
$2,318.80
|
| Rate for Payer: WPS Commercial |
$3,122.79
|
|
|
PLATE DISTAL FIBULA LATERAL 3HL 40-20903
|
Facility
|
IP
|
$4,216.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415586
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,065.84 |
| Max. Negotiated Rate |
$3,878.72 |
| Rate for Payer: Aetna Commercial |
$3,794.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,625.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,234.48
|
| Rate for Payer: Cash Price |
$1,264.80
|
| Rate for Payer: Cigna Commercial |
$3,878.72
|
| Rate for Payer: Health EOS Commercial |
$3,752.24
|
| Rate for Payer: HFN Commercial |
$3,878.72
|
| Rate for Payer: Multiplan Commercial |
$3,372.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,529.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,878.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,065.84
|
| Rate for Payer: Quartz Commercial |
$2,529.60
|
| Rate for Payer: WEA Trust Commercial |
$2,318.80
|
| Rate for Payer: WPS Commercial |
$3,122.79
|
|
|
PLATE DISTAL FIBULA LATERAL 4HL 40-20904
|
Facility
|
OP
|
$4,213.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.64 |
| Max. Negotiated Rate |
$16,852.00 |
| Rate for Payer: Aetna Commercial |
$3,791.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,623.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,179.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,738.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,106.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,022.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,232.89
|
| Rate for Payer: Cash Price |
$1,263.90
|
| Rate for Payer: Cigna Commercial |
$3,875.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,357.59
|
| Rate for Payer: Health EOS Commercial |
$3,749.57
|
| Rate for Payer: HFN Commercial |
$3,875.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,159.75
|
| Rate for Payer: Multiplan Commercial |
$3,370.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,527.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,875.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,064.37
|
| Rate for Payer: Quartz Commercial |
$2,738.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,527.80
|
| Rate for Payer: The Alliance Commercial |
$16,852.00
|
| Rate for Payer: WEA Trust Commercial |
$2,317.15
|
| Rate for Payer: WPS Commercial |
$3,120.57
|
|
|
PLATE DISTAL FIBULA LATERAL 4HL 40-20904
|
Facility
|
IP
|
$4,213.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,064.37 |
| Max. Negotiated Rate |
$3,875.96 |
| Rate for Payer: Aetna Commercial |
$3,791.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,623.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,232.89
|
| Rate for Payer: Cash Price |
$1,263.90
|
| Rate for Payer: Cigna Commercial |
$3,875.96
|
| Rate for Payer: Health EOS Commercial |
$3,749.57
|
| Rate for Payer: HFN Commercial |
$3,875.96
|
| Rate for Payer: Multiplan Commercial |
$3,370.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,527.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,875.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,064.37
|
| Rate for Payer: Quartz Commercial |
$2,527.80
|
| Rate for Payer: WEA Trust Commercial |
$2,317.15
|
| Rate for Payer: WPS Commercial |
$3,120.57
|
|
|
PLATE DISTAL FIBULA LATERAL 5HL 40-20905
|
Facility
|
IP
|
$4,560.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5603671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,234.40 |
| Max. Negotiated Rate |
$4,195.20 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
PLATE DISTAL FIBULA LATERAL 5HL 40-20905
|
Facility
|
OP
|
$4,560.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5603671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,276.80 |
| Max. Negotiated Rate |
$18,240.00 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,276.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,964.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,280.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,188.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,551.78
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,420.00
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,736.00
|
| Rate for Payer: The Alliance Commercial |
$18,240.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
PLATE DISTAL FIBULA LOCK 4HL RT ARTHREX AR-8943BR-04
|
Facility
|
IP
|
$4,388.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5416060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.12 |
| Max. Negotiated Rate |
$4,036.96 |
| Rate for Payer: Aetna Commercial |
$3,949.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,773.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,325.64
|
| Rate for Payer: Cash Price |
$1,316.40
|
| Rate for Payer: Cigna Commercial |
$4,036.96
|
| Rate for Payer: Health EOS Commercial |
$3,905.32
|
| Rate for Payer: HFN Commercial |
$4,036.96
|
| Rate for Payer: Multiplan Commercial |
$3,510.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,632.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,036.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,150.12
|
| Rate for Payer: Quartz Commercial |
$2,632.80
|
| Rate for Payer: WEA Trust Commercial |
$2,413.40
|
| Rate for Payer: WPS Commercial |
$3,250.19
|
|
|
PLATE DISTAL FIBULA LOCK 4HL RT ARTHREX AR-8943BR-04
|
Facility
|
OP
|
$4,388.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5416060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,228.64 |
| Max. Negotiated Rate |
$17,552.00 |
| Rate for Payer: Aetna Commercial |
$3,949.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,773.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,228.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,852.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,194.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,106.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,325.64
|
| Rate for Payer: Cash Price |
$1,316.40
|
| Rate for Payer: Cigna Commercial |
$4,036.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,455.52
|
| Rate for Payer: Health EOS Commercial |
$3,905.32
|
| Rate for Payer: HFN Commercial |
$4,036.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,291.00
|
| Rate for Payer: Multiplan Commercial |
$3,510.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,632.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,036.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,150.12
|
| Rate for Payer: Quartz Commercial |
$2,852.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,632.80
|
| Rate for Payer: The Alliance Commercial |
$17,552.00
|
| Rate for Payer: WEA Trust Commercial |
$2,413.40
|
| Rate for Payer: WPS Commercial |
$3,250.19
|
|
|
PLATE DISTAL FIBULA LOCK 5HL RT ARTHREX AR-8943BR-05
|
Facility
|
OP
|
$4,986.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,396.08 |
| Max. Negotiated Rate |
$19,944.00 |
| Rate for Payer: Aetna Commercial |
$4,487.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,287.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,396.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,240.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,493.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,393.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,642.58
|
| Rate for Payer: Cash Price |
$1,495.80
|
| Rate for Payer: Cigna Commercial |
$4,587.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,790.17
|
| Rate for Payer: Health EOS Commercial |
$4,437.54
|
| Rate for Payer: HFN Commercial |
$4,587.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,739.50
|
| Rate for Payer: Multiplan Commercial |
$3,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,991.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,587.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,443.14
|
| Rate for Payer: Quartz Commercial |
$3,240.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,991.60
|
| Rate for Payer: The Alliance Commercial |
$19,944.00
|
| Rate for Payer: WEA Trust Commercial |
$2,742.30
|
| Rate for Payer: WPS Commercial |
$3,693.13
|
|
|
PLATE DISTAL FIBULA LOCK 5HL RT ARTHREX AR-8943BR-05
|
Facility
|
IP
|
$4,986.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,443.14 |
| Max. Negotiated Rate |
$4,587.12 |
| Rate for Payer: Aetna Commercial |
$4,487.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,287.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,642.58
|
| Rate for Payer: Cash Price |
$1,495.80
|
| Rate for Payer: Cigna Commercial |
$4,587.12
|
| Rate for Payer: Health EOS Commercial |
$4,437.54
|
| Rate for Payer: HFN Commercial |
$4,587.12
|
| Rate for Payer: Multiplan Commercial |
$3,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,991.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,587.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,443.14
|
| Rate for Payer: Quartz Commercial |
$2,991.60
|
| Rate for Payer: WEA Trust Commercial |
$2,742.30
|
| Rate for Payer: WPS Commercial |
$3,693.13
|
|
|
PLATE DISTAL FIBULA LOCK LT 5HL AR-8943DL-05
|
Facility
|
IP
|
$5,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6199044
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,545.06 |
| Max. Negotiated Rate |
$4,778.48 |
| Rate for Payer: Aetna Commercial |
$4,674.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,466.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,752.82
|
| Rate for Payer: Cash Price |
$1,558.20
|
| Rate for Payer: Cigna Commercial |
$4,778.48
|
| Rate for Payer: Health EOS Commercial |
$4,622.66
|
| Rate for Payer: HFN Commercial |
$4,778.48
|
| Rate for Payer: Multiplan Commercial |
$4,155.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,778.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,545.06
|
| Rate for Payer: Quartz Commercial |
$3,116.40
|
| Rate for Payer: WEA Trust Commercial |
$2,856.70
|
| Rate for Payer: WPS Commercial |
$3,847.20
|
|
|
PLATE DISTAL FIBULA LOCK LT 5HL AR-8943DL-05
|
Facility
|
OP
|
$5,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6199044
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,454.32 |
| Max. Negotiated Rate |
$20,776.00 |
| Rate for Payer: Aetna Commercial |
$4,674.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,466.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,454.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,376.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,597.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,493.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,752.82
|
| Rate for Payer: Cash Price |
$1,558.20
|
| Rate for Payer: Cigna Commercial |
$4,778.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,906.56
|
| Rate for Payer: Health EOS Commercial |
$4,622.66
|
| Rate for Payer: HFN Commercial |
$4,778.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,895.50
|
| Rate for Payer: Multiplan Commercial |
$4,155.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,778.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,545.06
|
| Rate for Payer: Quartz Commercial |
$3,376.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,116.40
|
| Rate for Payer: The Alliance Commercial |
$20,776.00
|
| Rate for Payer: WEA Trust Commercial |
$2,856.70
|
| Rate for Payer: WPS Commercial |
$3,847.20
|
|
|
PLATE DISTAL FIBULA LOCK LT 5HL ARTHREX AR-8943BL-05
|
Facility
|
IP
|
$5,185.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,540.65 |
| Max. Negotiated Rate |
$4,770.20 |
| Rate for Payer: Aetna Commercial |
$4,666.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,459.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,748.05
|
| Rate for Payer: Cash Price |
$1,555.50
|
| Rate for Payer: Cigna Commercial |
$4,770.20
|
| Rate for Payer: Health EOS Commercial |
$4,614.65
|
| Rate for Payer: HFN Commercial |
$4,770.20
|
| Rate for Payer: Multiplan Commercial |
$4,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,111.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,770.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,540.65
|
| Rate for Payer: Quartz Commercial |
$3,111.00
|
| Rate for Payer: WEA Trust Commercial |
$2,851.75
|
| Rate for Payer: WPS Commercial |
$3,840.53
|
|
|
PLATE DISTAL FIBULA LOCK LT 5HL ARTHREX AR-8943BL-05
|
Facility
|
OP
|
$5,185.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.80 |
| Max. Negotiated Rate |
$20,740.00 |
| Rate for Payer: Aetna Commercial |
$4,666.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,459.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,451.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,370.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,592.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,488.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,748.05
|
| Rate for Payer: Cash Price |
$1,555.50
|
| Rate for Payer: Cigna Commercial |
$4,770.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,901.53
|
| Rate for Payer: Health EOS Commercial |
$4,614.65
|
| Rate for Payer: HFN Commercial |
$4,770.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,888.75
|
| Rate for Payer: Multiplan Commercial |
$4,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,111.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,770.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,540.65
|
| Rate for Payer: Quartz Commercial |
$3,370.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,111.00
|
| Rate for Payer: The Alliance Commercial |
$20,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,851.75
|
| Rate for Payer: WPS Commercial |
$3,840.53
|
|
|
PLATE DISTAL FIBULA LOCK LT 6HL AR-8943DL-06
|
Facility
|
IP
|
$5,901.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6172090
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,891.49 |
| Max. Negotiated Rate |
$5,428.92 |
| Rate for Payer: Aetna Commercial |
$5,310.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,074.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,127.53
|
| Rate for Payer: Cash Price |
$1,770.30
|
| Rate for Payer: Cigna Commercial |
$5,428.92
|
| Rate for Payer: Health EOS Commercial |
$5,251.89
|
| Rate for Payer: HFN Commercial |
$5,428.92
|
| Rate for Payer: Multiplan Commercial |
$4,720.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,540.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,428.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,891.49
|
| Rate for Payer: Quartz Commercial |
$3,540.60
|
| Rate for Payer: WEA Trust Commercial |
$3,245.55
|
| Rate for Payer: WPS Commercial |
$4,370.87
|
|
|
PLATE DISTAL FIBULA LOCK LT 6HL AR-8943DL-06
|
Facility
|
OP
|
$5,901.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6172090
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,652.28 |
| Max. Negotiated Rate |
$23,604.00 |
| Rate for Payer: Aetna Commercial |
$5,310.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,074.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,652.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,835.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,950.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,832.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,127.53
|
| Rate for Payer: Cash Price |
$1,770.30
|
| Rate for Payer: Cigna Commercial |
$5,428.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,302.20
|
| Rate for Payer: Health EOS Commercial |
$5,251.89
|
| Rate for Payer: HFN Commercial |
$5,428.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,425.75
|
| Rate for Payer: Multiplan Commercial |
$4,720.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,540.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,428.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,891.49
|
| Rate for Payer: Quartz Commercial |
$3,835.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,540.60
|
| Rate for Payer: The Alliance Commercial |
$23,604.00
|
| Rate for Payer: WEA Trust Commercial |
$3,245.55
|
| Rate for Payer: WPS Commercial |
$4,370.87
|
|
|
PLATE DISTAL FIBULA LOCK LT 6HL ARTHREX AR-8943BL-06
|
Facility
|
OP
|
$5,348.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6173858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.44 |
| Max. Negotiated Rate |
$21,392.00 |
| Rate for Payer: Aetna Commercial |
$4,813.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,599.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,497.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,476.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,674.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,567.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,834.44
|
| Rate for Payer: Cash Price |
$1,604.40
|
| Rate for Payer: Cigna Commercial |
$4,920.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,992.74
|
| Rate for Payer: Health EOS Commercial |
$4,759.72
|
| Rate for Payer: HFN Commercial |
$4,920.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,011.00
|
| Rate for Payer: Multiplan Commercial |
$4,278.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,208.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,920.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,620.52
|
| Rate for Payer: Quartz Commercial |
$3,476.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,208.80
|
| Rate for Payer: The Alliance Commercial |
$21,392.00
|
| Rate for Payer: WEA Trust Commercial |
$2,941.40
|
| Rate for Payer: WPS Commercial |
$3,961.26
|
|
|
PLATE DISTAL FIBULA LOCK LT 6HL ARTHREX AR-8943BL-06
|
Facility
|
IP
|
$5,348.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6173858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,620.52 |
| Max. Negotiated Rate |
$4,920.16 |
| Rate for Payer: Aetna Commercial |
$4,813.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,599.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,834.44
|
| Rate for Payer: Cash Price |
$1,604.40
|
| Rate for Payer: Cigna Commercial |
$4,920.16
|
| Rate for Payer: Health EOS Commercial |
$4,759.72
|
| Rate for Payer: HFN Commercial |
$4,920.16
|
| Rate for Payer: Multiplan Commercial |
$4,278.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,208.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,920.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,620.52
|
| Rate for Payer: Quartz Commercial |
$3,208.80
|
| Rate for Payer: WEA Trust Commercial |
$2,941.40
|
| Rate for Payer: WPS Commercial |
$3,961.26
|
|
|
PLATE DISTAL FIBULA LOCK RT 5HL AR-8943DR-05
|
Facility
|
IP
|
$5,142.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6179753
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,519.58 |
| Max. Negotiated Rate |
$4,730.64 |
| Rate for Payer: Aetna Commercial |
$4,627.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,422.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,725.26
|
| Rate for Payer: Cash Price |
$1,542.60
|
| Rate for Payer: Cigna Commercial |
$4,730.64
|
| Rate for Payer: Health EOS Commercial |
$4,576.38
|
| Rate for Payer: HFN Commercial |
$4,730.64
|
| Rate for Payer: Multiplan Commercial |
$4,113.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,085.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,730.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,519.58
|
| Rate for Payer: Quartz Commercial |
$3,085.20
|
| Rate for Payer: WEA Trust Commercial |
$2,828.10
|
| Rate for Payer: WPS Commercial |
$3,808.68
|
|
|
PLATE DISTAL FIBULA LOCK RT 5HL AR-8943DR-05
|
Facility
|
OP
|
$5,142.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6179753
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.76 |
| Max. Negotiated Rate |
$20,568.00 |
| Rate for Payer: Aetna Commercial |
$4,627.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,422.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,439.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,342.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,571.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,468.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,725.26
|
| Rate for Payer: Cash Price |
$1,542.60
|
| Rate for Payer: Cigna Commercial |
$4,730.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,877.46
|
| Rate for Payer: Health EOS Commercial |
$4,576.38
|
| Rate for Payer: HFN Commercial |
$4,730.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,856.50
|
| Rate for Payer: Multiplan Commercial |
$4,113.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,085.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,730.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,519.58
|
| Rate for Payer: Quartz Commercial |
$3,342.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,085.20
|
| Rate for Payer: The Alliance Commercial |
$20,568.00
|
| Rate for Payer: WEA Trust Commercial |
$2,828.10
|
| Rate for Payer: WPS Commercial |
$3,808.68
|
|
|
PLATE DISTAL FIBULA LOCK RT 6H AR-8943BR-06
|
Facility
|
OP
|
$5,784.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5456672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,619.52 |
| Max. Negotiated Rate |
$23,136.00 |
| Rate for Payer: Aetna Commercial |
$5,205.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,974.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,619.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,759.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,892.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,776.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,065.52
|
| Rate for Payer: Cash Price |
$1,735.20
|
| Rate for Payer: Cigna Commercial |
$5,321.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,236.73
|
| Rate for Payer: Health EOS Commercial |
$5,147.76
|
| Rate for Payer: HFN Commercial |
$5,321.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,338.00
|
| Rate for Payer: Multiplan Commercial |
$4,627.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,470.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,321.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,834.16
|
| Rate for Payer: Quartz Commercial |
$3,759.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,470.40
|
| Rate for Payer: The Alliance Commercial |
$23,136.00
|
| Rate for Payer: WEA Trust Commercial |
$3,181.20
|
| Rate for Payer: WPS Commercial |
$4,284.21
|
|
|
PLATE DISTAL FIBULA LOCK RT 6H AR-8943BR-06
|
Facility
|
IP
|
$5,784.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5456672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,834.16 |
| Max. Negotiated Rate |
$5,321.28 |
| Rate for Payer: Aetna Commercial |
$5,205.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,974.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,065.52
|
| Rate for Payer: Cash Price |
$1,735.20
|
| Rate for Payer: Cigna Commercial |
$5,321.28
|
| Rate for Payer: Health EOS Commercial |
$5,147.76
|
| Rate for Payer: HFN Commercial |
$5,321.28
|
| Rate for Payer: Multiplan Commercial |
$4,627.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,470.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,321.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,834.16
|
| Rate for Payer: Quartz Commercial |
$3,470.40
|
| Rate for Payer: WEA Trust Commercial |
$3,181.20
|
| Rate for Payer: WPS Commercial |
$4,284.21
|
|
|
PLATE DISTAL FIBULA LOCK RT 6HL AR-8943DR-06
|
Facility
|
OP
|
$5,674.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,588.72 |
| Max. Negotiated Rate |
$22,696.00 |
| Rate for Payer: Aetna Commercial |
$5,106.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,588.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,688.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,837.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,723.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.22
|
| Rate for Payer: Cash Price |
$1,702.20
|
| Rate for Payer: Cigna Commercial |
$5,220.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,175.17
|
| Rate for Payer: Health EOS Commercial |
$5,049.86
|
| Rate for Payer: HFN Commercial |
$5,220.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,255.50
|
| Rate for Payer: Multiplan Commercial |
$4,539.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,404.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.26
|
| Rate for Payer: Quartz Commercial |
$3,688.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,404.40
|
| Rate for Payer: The Alliance Commercial |
$22,696.00
|
| Rate for Payer: WEA Trust Commercial |
$3,120.70
|
| Rate for Payer: WPS Commercial |
$4,202.73
|
|
|
PLATE DISTAL FIBULA LOCK RT 6HL AR-8943DR-06
|
Facility
|
IP
|
$5,674.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,780.26 |
| Max. Negotiated Rate |
$5,220.08 |
| Rate for Payer: Aetna Commercial |
$5,106.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.22
|
| Rate for Payer: Cash Price |
$1,702.20
|
| Rate for Payer: Cigna Commercial |
$5,220.08
|
| Rate for Payer: Health EOS Commercial |
$5,049.86
|
| Rate for Payer: HFN Commercial |
$5,220.08
|
| Rate for Payer: Multiplan Commercial |
$4,539.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,404.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.26
|
| Rate for Payer: Quartz Commercial |
$3,404.40
|
| Rate for Payer: WEA Trust Commercial |
$3,120.70
|
| Rate for Payer: WPS Commercial |
$4,202.73
|
|
