|
PLATE LAT/DIS/FIBULA 11H/LT 02.118.413
|
Facility
|
OP
|
$6,110.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,710.80 |
| Max. Negotiated Rate |
$24,440.00 |
| Rate for Payer: Aetna Commercial |
$5,499.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,254.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,710.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,971.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,055.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,932.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,238.30
|
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Cigna Commercial |
$5,621.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,419.16
|
| Rate for Payer: Health EOS Commercial |
$5,437.90
|
| Rate for Payer: HFN Commercial |
$5,621.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,582.50
|
| Rate for Payer: Multiplan Commercial |
$4,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,666.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,621.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,993.90
|
| Rate for Payer: Quartz Commercial |
$3,971.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,666.00
|
| Rate for Payer: The Alliance Commercial |
$24,440.00
|
| Rate for Payer: WEA Trust Commercial |
$3,360.50
|
| Rate for Payer: WPS Commercial |
$4,525.68
|
|
|
PLATE LAT/DIS/FIBULA 11H/LT 02.118.413
|
Facility
|
IP
|
$6,110.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,993.90 |
| Max. Negotiated Rate |
$5,621.20 |
| Rate for Payer: Aetna Commercial |
$5,499.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,254.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,238.30
|
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Cigna Commercial |
$5,621.20
|
| Rate for Payer: Health EOS Commercial |
$5,437.90
|
| Rate for Payer: HFN Commercial |
$5,621.20
|
| Rate for Payer: Multiplan Commercial |
$4,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,666.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,621.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,993.90
|
| Rate for Payer: Quartz Commercial |
$3,666.00
|
| Rate for Payer: WEA Trust Commercial |
$3,360.50
|
| Rate for Payer: WPS Commercial |
$4,525.68
|
|
|
PLATE LAT/DIS/FIBULA 13H/LT 02.118.415
|
Facility
|
OP
|
$6,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,790.32 |
| Max. Negotiated Rate |
$25,576.00 |
| Rate for Payer: Aetna Commercial |
$5,754.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,498.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,790.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,156.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,197.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,069.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,388.82
|
| Rate for Payer: Cash Price |
$1,918.20
|
| Rate for Payer: Cigna Commercial |
$5,882.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,578.08
|
| Rate for Payer: Health EOS Commercial |
$5,690.66
|
| Rate for Payer: HFN Commercial |
$5,882.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,795.50
|
| Rate for Payer: Multiplan Commercial |
$5,115.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,836.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,882.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,133.06
|
| Rate for Payer: Quartz Commercial |
$4,156.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,836.40
|
| Rate for Payer: The Alliance Commercial |
$25,576.00
|
| Rate for Payer: WEA Trust Commercial |
$3,516.70
|
| Rate for Payer: WPS Commercial |
$4,736.04
|
|
|
PLATE LAT/DIS/FIBULA 13H/LT 02.118.415
|
Facility
|
IP
|
$6,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,133.06 |
| Max. Negotiated Rate |
$5,882.48 |
| Rate for Payer: Aetna Commercial |
$5,754.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,498.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,388.82
|
| Rate for Payer: Cash Price |
$1,918.20
|
| Rate for Payer: Cigna Commercial |
$5,882.48
|
| Rate for Payer: Health EOS Commercial |
$5,690.66
|
| Rate for Payer: HFN Commercial |
$5,882.48
|
| Rate for Payer: Multiplan Commercial |
$5,115.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,836.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,882.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,133.06
|
| Rate for Payer: Quartz Commercial |
$3,836.40
|
| Rate for Payer: WEA Trust Commercial |
$3,516.70
|
| Rate for Payer: WPS Commercial |
$4,736.04
|
|
|
PLATE LAT/DIS/FIBULA 13H/RT 02.118.414
|
Facility
|
IP
|
$6,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,133.06 |
| Max. Negotiated Rate |
$5,882.48 |
| Rate for Payer: Aetna Commercial |
$5,754.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,498.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,388.82
|
| Rate for Payer: Cash Price |
$1,918.20
|
| Rate for Payer: Cigna Commercial |
$5,882.48
|
| Rate for Payer: Health EOS Commercial |
$5,690.66
|
| Rate for Payer: HFN Commercial |
$5,882.48
|
| Rate for Payer: Multiplan Commercial |
$5,115.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,836.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,882.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,133.06
|
| Rate for Payer: Quartz Commercial |
$3,836.40
|
| Rate for Payer: WEA Trust Commercial |
$3,516.70
|
| Rate for Payer: WPS Commercial |
$4,736.04
|
|
|
PLATE LAT/DIS/FIBULA 13H/RT 02.118.414
|
Facility
|
OP
|
$6,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,790.32 |
| Max. Negotiated Rate |
$25,576.00 |
| Rate for Payer: Aetna Commercial |
$5,754.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,498.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,790.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,156.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,197.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,069.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,388.82
|
| Rate for Payer: Cash Price |
$1,918.20
|
| Rate for Payer: Cigna Commercial |
$5,882.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,578.08
|
| Rate for Payer: Health EOS Commercial |
$5,690.66
|
| Rate for Payer: HFN Commercial |
$5,882.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,795.50
|
| Rate for Payer: Multiplan Commercial |
$5,115.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,836.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,882.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,133.06
|
| Rate for Payer: Quartz Commercial |
$4,156.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,836.40
|
| Rate for Payer: The Alliance Commercial |
$25,576.00
|
| Rate for Payer: WEA Trust Commercial |
$3,516.70
|
| Rate for Payer: WPS Commercial |
$4,736.04
|
|
|
PLATE LAT/DIS/FIBULA 6H/RT 02.118.406
|
Facility
|
OP
|
$8,286.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,320.08 |
| Max. Negotiated Rate |
$33,144.00 |
| Rate for Payer: Aetna Commercial |
$7,457.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,125.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,320.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,385.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,143.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,977.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,391.58
|
| Rate for Payer: Cash Price |
$2,485.80
|
| Rate for Payer: Cigna Commercial |
$7,623.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,636.85
|
| Rate for Payer: Health EOS Commercial |
$7,374.54
|
| Rate for Payer: HFN Commercial |
$7,623.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,214.50
|
| Rate for Payer: Multiplan Commercial |
$6,628.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,971.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,623.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,060.14
|
| Rate for Payer: Quartz Commercial |
$5,385.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,971.60
|
| Rate for Payer: The Alliance Commercial |
$33,144.00
|
| Rate for Payer: WEA Trust Commercial |
$4,557.30
|
| Rate for Payer: WPS Commercial |
$6,137.44
|
|
|
PLATE LAT/DIS/FIBULA 6H/RT 02.118.406
|
Facility
|
IP
|
$8,286.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,060.14 |
| Max. Negotiated Rate |
$7,623.12 |
| Rate for Payer: Aetna Commercial |
$7,457.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,125.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,391.58
|
| Rate for Payer: Cash Price |
$2,485.80
|
| Rate for Payer: Cigna Commercial |
$7,623.12
|
| Rate for Payer: Health EOS Commercial |
$7,374.54
|
| Rate for Payer: HFN Commercial |
$7,623.12
|
| Rate for Payer: Multiplan Commercial |
$6,628.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,971.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,623.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,060.14
|
| Rate for Payer: Quartz Commercial |
$4,971.60
|
| Rate for Payer: WEA Trust Commercial |
$4,557.30
|
| Rate for Payer: WPS Commercial |
$6,137.44
|
|
|
PLATE LAT/DIS/FIBULA 7H/LT 02.118.409
|
Facility
|
IP
|
$8,365.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,098.85 |
| Max. Negotiated Rate |
$7,695.80 |
| Rate for Payer: Aetna Commercial |
$7,528.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,193.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,433.45
|
| Rate for Payer: Cash Price |
$2,509.50
|
| Rate for Payer: Cigna Commercial |
$7,695.80
|
| Rate for Payer: Health EOS Commercial |
$7,444.85
|
| Rate for Payer: HFN Commercial |
$7,695.80
|
| Rate for Payer: Multiplan Commercial |
$6,692.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,019.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,695.80
|
| Rate for Payer: Quartz Beloit One Network |
$4,098.85
|
| Rate for Payer: Quartz Commercial |
$5,019.00
|
| Rate for Payer: WEA Trust Commercial |
$4,600.75
|
| Rate for Payer: WPS Commercial |
$6,195.96
|
|
|
PLATE LAT/DIS/FIBULA 7H/LT 02.118.409
|
Facility
|
OP
|
$8,365.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,342.20 |
| Max. Negotiated Rate |
$33,460.00 |
| Rate for Payer: Aetna Commercial |
$7,528.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,193.90
|
| Rate for Payer: Aetna Managed Medicare |
$2,342.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,437.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,182.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,015.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,433.45
|
| Rate for Payer: Cash Price |
$2,509.50
|
| Rate for Payer: Cigna Commercial |
$7,695.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,681.05
|
| Rate for Payer: Health EOS Commercial |
$7,444.85
|
| Rate for Payer: HFN Commercial |
$7,695.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,273.75
|
| Rate for Payer: Multiplan Commercial |
$6,692.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,019.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,695.80
|
| Rate for Payer: Quartz Beloit One Network |
$4,098.85
|
| Rate for Payer: Quartz Commercial |
$5,437.25
|
| Rate for Payer: Quartz Medicare Advantage |
$5,019.00
|
| Rate for Payer: The Alliance Commercial |
$33,460.00
|
| Rate for Payer: WEA Trust Commercial |
$4,600.75
|
| Rate for Payer: WPS Commercial |
$6,195.96
|
|
|
PLATE LAT/DIS/FIBULA 7H/RT 02.118.408
|
Facility
|
IP
|
$8,365.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520508
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,098.85 |
| Max. Negotiated Rate |
$7,695.80 |
| Rate for Payer: Aetna Commercial |
$7,528.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,193.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,433.45
|
| Rate for Payer: Cash Price |
$2,509.50
|
| Rate for Payer: Cigna Commercial |
$7,695.80
|
| Rate for Payer: Health EOS Commercial |
$7,444.85
|
| Rate for Payer: HFN Commercial |
$7,695.80
|
| Rate for Payer: Multiplan Commercial |
$6,692.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,019.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,695.80
|
| Rate for Payer: Quartz Beloit One Network |
$4,098.85
|
| Rate for Payer: Quartz Commercial |
$5,019.00
|
| Rate for Payer: WEA Trust Commercial |
$4,600.75
|
| Rate for Payer: WPS Commercial |
$6,195.96
|
|
|
PLATE LAT/DIS/FIBULA 7H/RT 02.118.408
|
Facility
|
OP
|
$8,365.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520508
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,342.20 |
| Max. Negotiated Rate |
$33,460.00 |
| Rate for Payer: Aetna Commercial |
$7,528.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,193.90
|
| Rate for Payer: Aetna Managed Medicare |
$2,342.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,437.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,182.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,015.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,433.45
|
| Rate for Payer: Cash Price |
$2,509.50
|
| Rate for Payer: Cigna Commercial |
$7,695.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,681.05
|
| Rate for Payer: Health EOS Commercial |
$7,444.85
|
| Rate for Payer: HFN Commercial |
$7,695.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,273.75
|
| Rate for Payer: Multiplan Commercial |
$6,692.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,019.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,695.80
|
| Rate for Payer: Quartz Beloit One Network |
$4,098.85
|
| Rate for Payer: Quartz Commercial |
$5,437.25
|
| Rate for Payer: Quartz Medicare Advantage |
$5,019.00
|
| Rate for Payer: The Alliance Commercial |
$33,460.00
|
| Rate for Payer: WEA Trust Commercial |
$4,600.75
|
| Rate for Payer: WPS Commercial |
$6,195.96
|
|
|
PLATE LAT/DIS/FIBULA 9H/LT 02.118.411
|
Facility
|
OP
|
$8,752.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,450.56 |
| Max. Negotiated Rate |
$35,008.00 |
| Rate for Payer: Aetna Commercial |
$7,876.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,526.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,450.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,688.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,376.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,200.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,638.56
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$8,051.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,897.62
|
| Rate for Payer: Health EOS Commercial |
$7,789.28
|
| Rate for Payer: HFN Commercial |
$8,051.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,564.00
|
| Rate for Payer: Multiplan Commercial |
$7,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,251.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,051.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,288.48
|
| Rate for Payer: Quartz Commercial |
$5,688.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,251.20
|
| Rate for Payer: The Alliance Commercial |
$35,008.00
|
| Rate for Payer: WEA Trust Commercial |
$4,813.60
|
| Rate for Payer: WPS Commercial |
$6,482.61
|
|
|
PLATE LAT/DIS/FIBULA 9H/LT 02.118.411
|
Facility
|
IP
|
$8,752.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,288.48 |
| Max. Negotiated Rate |
$8,051.84 |
| Rate for Payer: Aetna Commercial |
$7,876.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,526.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,638.56
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$8,051.84
|
| Rate for Payer: Health EOS Commercial |
$7,789.28
|
| Rate for Payer: HFN Commercial |
$8,051.84
|
| Rate for Payer: Multiplan Commercial |
$7,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,251.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,051.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,288.48
|
| Rate for Payer: Quartz Commercial |
$5,251.20
|
| Rate for Payer: WEA Trust Commercial |
$4,813.60
|
| Rate for Payer: WPS Commercial |
$6,482.61
|
|
|
PLATE LAT/DIS/FIBULA 9H/RT 02.118.410
|
Facility
|
IP
|
$8,752.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,288.48 |
| Max. Negotiated Rate |
$8,051.84 |
| Rate for Payer: Aetna Commercial |
$7,876.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,526.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,638.56
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$8,051.84
|
| Rate for Payer: Health EOS Commercial |
$7,789.28
|
| Rate for Payer: HFN Commercial |
$8,051.84
|
| Rate for Payer: Multiplan Commercial |
$7,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,251.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,051.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,288.48
|
| Rate for Payer: Quartz Commercial |
$5,251.20
|
| Rate for Payer: WEA Trust Commercial |
$4,813.60
|
| Rate for Payer: WPS Commercial |
$6,482.61
|
|
|
PLATE LAT/DIS/FIBULA 9H/RT 02.118.410
|
Facility
|
OP
|
$8,752.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,450.56 |
| Max. Negotiated Rate |
$35,008.00 |
| Rate for Payer: Aetna Commercial |
$7,876.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,526.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,450.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,688.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,376.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,200.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,638.56
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$8,051.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,897.62
|
| Rate for Payer: Health EOS Commercial |
$7,789.28
|
| Rate for Payer: HFN Commercial |
$8,051.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,564.00
|
| Rate for Payer: Multiplan Commercial |
$7,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,251.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,051.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,288.48
|
| Rate for Payer: Quartz Commercial |
$5,688.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,251.20
|
| Rate for Payer: The Alliance Commercial |
$35,008.00
|
| Rate for Payer: WEA Trust Commercial |
$4,813.60
|
| Rate for Payer: WPS Commercial |
$6,482.61
|
|
|
PLATE LATERAL DISTAL FIBULA 2.7/3.5 3HL LT 02.112.137
|
Facility
|
IP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3365524
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
PLATE LATERAL DISTAL FIBULA 2.7/3.5 3HL LT 02.112.137
|
Facility
|
OP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3365524
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
PLATE LATERAL DISTAL FIBULA 5HL LT 02.112.141
|
Facility
|
OP
|
$5,218.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4518955
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.04 |
| Max. Negotiated Rate |
$20,872.00 |
| Rate for Payer: Aetna Commercial |
$4,696.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,487.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,461.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,391.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,609.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,504.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,765.54
|
| Rate for Payer: Cash Price |
$1,565.40
|
| Rate for Payer: Cigna Commercial |
$4,800.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,919.99
|
| Rate for Payer: Health EOS Commercial |
$4,644.02
|
| Rate for Payer: HFN Commercial |
$4,800.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,913.50
|
| Rate for Payer: Multiplan Commercial |
$4,174.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,130.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,800.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,556.82
|
| Rate for Payer: Quartz Commercial |
$3,391.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,130.80
|
| Rate for Payer: The Alliance Commercial |
$20,872.00
|
| Rate for Payer: WEA Trust Commercial |
$2,869.90
|
| Rate for Payer: WPS Commercial |
$3,864.97
|
|
|
PLATE LATERAL DISTAL FIBULA 5HL LT 02.112.141
|
Facility
|
IP
|
$5,218.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4518955
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,556.82 |
| Max. Negotiated Rate |
$4,800.56 |
| Rate for Payer: Aetna Commercial |
$4,696.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,487.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,765.54
|
| Rate for Payer: Cash Price |
$1,565.40
|
| Rate for Payer: Cigna Commercial |
$4,800.56
|
| Rate for Payer: Health EOS Commercial |
$4,644.02
|
| Rate for Payer: HFN Commercial |
$4,800.56
|
| Rate for Payer: Multiplan Commercial |
$4,174.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,130.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,800.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,556.82
|
| Rate for Payer: Quartz Commercial |
$3,130.80
|
| Rate for Payer: WEA Trust Commercial |
$2,869.90
|
| Rate for Payer: WPS Commercial |
$3,864.97
|
|
|
PLATE LATERAL DISTAL FIBULA 7HL RT 02.112.144
|
Facility
|
OP
|
$6,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966370
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,745.80 |
| Max. Negotiated Rate |
$24,940.00 |
| Rate for Payer: Aetna Commercial |
$5,611.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,745.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,052.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,117.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,992.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,304.55
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,736.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,489.11
|
| Rate for Payer: Health EOS Commercial |
$5,549.15
|
| Rate for Payer: HFN Commercial |
$5,736.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,676.25
|
| Rate for Payer: Multiplan Commercial |
$4,988.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,736.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.15
|
| Rate for Payer: Quartz Commercial |
$4,052.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3,741.00
|
| Rate for Payer: The Alliance Commercial |
$24,940.00
|
| Rate for Payer: WEA Trust Commercial |
$3,429.25
|
| Rate for Payer: WPS Commercial |
$4,618.26
|
|
|
PLATE LATERAL DISTAL FIBULA 7HL RT 02.112.144
|
Facility
|
IP
|
$6,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966370
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,055.15 |
| Max. Negotiated Rate |
$5,736.20 |
| Rate for Payer: Aetna Commercial |
$5,611.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,304.55
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,736.20
|
| Rate for Payer: Health EOS Commercial |
$5,549.15
|
| Rate for Payer: HFN Commercial |
$5,736.20
|
| Rate for Payer: Multiplan Commercial |
$4,988.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,736.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.15
|
| Rate for Payer: Quartz Commercial |
$3,741.00
|
| Rate for Payer: WEA Trust Commercial |
$3,429.25
|
| Rate for Payer: WPS Commercial |
$4,618.26
|
|
|
PLATE LATERAL FUSION TTC SM RT ORTHOLOC 5920301R
|
Facility
|
OP
|
$11,746.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6201058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,288.88 |
| Max. Negotiated Rate |
$46,984.00 |
| Rate for Payer: Aetna Commercial |
$10,571.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,101.56
|
| Rate for Payer: Aetna Managed Medicare |
$3,288.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,634.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,873.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,638.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,225.38
|
| Rate for Payer: Cash Price |
$3,523.80
|
| Rate for Payer: Cigna Commercial |
$10,806.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,573.06
|
| Rate for Payer: Health EOS Commercial |
$10,453.94
|
| Rate for Payer: HFN Commercial |
$10,806.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,809.50
|
| Rate for Payer: Multiplan Commercial |
$9,396.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,047.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,806.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,755.54
|
| Rate for Payer: Quartz Commercial |
$7,634.90
|
| Rate for Payer: Quartz Medicare Advantage |
$7,047.60
|
| Rate for Payer: The Alliance Commercial |
$46,984.00
|
| Rate for Payer: WEA Trust Commercial |
$6,460.30
|
| Rate for Payer: WPS Commercial |
$8,700.26
|
|
|
PLATE LATERAL FUSION TTC SM RT ORTHOLOC 5920301R
|
Facility
|
IP
|
$11,746.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6201058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,755.54 |
| Max. Negotiated Rate |
$10,806.32 |
| Rate for Payer: Aetna Commercial |
$10,571.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,101.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,225.38
|
| Rate for Payer: Cash Price |
$3,523.80
|
| Rate for Payer: Cigna Commercial |
$10,806.32
|
| Rate for Payer: Health EOS Commercial |
$10,453.94
|
| Rate for Payer: HFN Commercial |
$10,806.32
|
| Rate for Payer: Multiplan Commercial |
$9,396.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,047.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,806.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,755.54
|
| Rate for Payer: Quartz Commercial |
$7,047.60
|
| Rate for Payer: WEA Trust Commercial |
$6,460.30
|
| Rate for Payer: WPS Commercial |
$8,700.26
|
|
|
PLATE L-BUTTRESS 4HL RT 240.44
|
Facility
|
OP
|
$1,588.00
|
|
| Hospital Charge Code |
2966759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$444.64 |
| Max. Negotiated Rate |
$6,352.00 |
| Rate for Payer: Aetna Commercial |
$1,429.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,365.68
|
| Rate for Payer: Aetna Managed Medicare |
$444.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,032.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$794.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$762.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$841.64
|
| Rate for Payer: Cash Price |
$476.40
|
| Rate for Payer: Cigna Commercial |
$1,460.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$888.64
|
| Rate for Payer: Health EOS Commercial |
$1,413.32
|
| Rate for Payer: HFN Commercial |
$1,460.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,191.00
|
| Rate for Payer: Multiplan Commercial |
$1,270.40
|
| Rate for Payer: NAPHCARE Commercial |
$952.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,460.96
|
| Rate for Payer: Quartz Beloit One Network |
$778.12
|
| Rate for Payer: Quartz Commercial |
$1,032.20
|
| Rate for Payer: Quartz Medicare Advantage |
$952.80
|
| Rate for Payer: The Alliance Commercial |
$6,352.00
|
| Rate for Payer: WEA Trust Commercial |
$873.40
|
| Rate for Payer: WPS Commercial |
$1,176.23
|
|
