|
PLATE L-BUTTRESS 4HL RT 240.44
|
Facility
|
IP
|
$1,588.00
|
|
| Hospital Charge Code |
2966759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$778.12 |
| Max. Negotiated Rate |
$1,460.96 |
| Rate for Payer: Aetna Commercial |
$1,429.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,365.68
|
| 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: Health EOS Commercial |
$1,413.32
|
| Rate for Payer: HFN Commercial |
$1,460.96
|
| 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 |
$952.80
|
| Rate for Payer: WEA Trust Commercial |
$873.40
|
| Rate for Payer: WPS Commercial |
$1,176.23
|
|
|
PLATE LC-DCP 2.0MM 6H/39MM 243.586
|
Facility
|
OP
|
$4,306.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508861
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,205.68 |
| Max. Negotiated Rate |
$17,224.00 |
| Rate for Payer: Aetna Commercial |
$3,875.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,703.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,205.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,798.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,153.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,066.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,282.18
|
| Rate for Payer: Cash Price |
$1,291.80
|
| Rate for Payer: Cigna Commercial |
$3,961.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,409.64
|
| Rate for Payer: Health EOS Commercial |
$3,832.34
|
| Rate for Payer: HFN Commercial |
$3,961.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,229.50
|
| Rate for Payer: Multiplan Commercial |
$3,444.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,583.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,961.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,109.94
|
| Rate for Payer: Quartz Commercial |
$2,798.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,583.60
|
| Rate for Payer: The Alliance Commercial |
$17,224.00
|
| Rate for Payer: WEA Trust Commercial |
$2,368.30
|
| Rate for Payer: WPS Commercial |
$3,189.45
|
|
|
PLATE LC-DCP 2.0MM 6H/39MM 243.586
|
Facility
|
IP
|
$4,306.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508861
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,109.94 |
| Max. Negotiated Rate |
$3,961.52 |
| Rate for Payer: Aetna Commercial |
$3,875.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,703.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,282.18
|
| Rate for Payer: Cash Price |
$1,291.80
|
| Rate for Payer: Cigna Commercial |
$3,961.52
|
| Rate for Payer: Health EOS Commercial |
$3,832.34
|
| Rate for Payer: HFN Commercial |
$3,961.52
|
| Rate for Payer: Multiplan Commercial |
$3,444.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,583.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,961.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,109.94
|
| Rate for Payer: Quartz Commercial |
$2,583.60
|
| Rate for Payer: WEA Trust Commercial |
$2,368.30
|
| Rate for Payer: WPS Commercial |
$3,189.45
|
|
|
PLATE LC-DCP 2.4MM 4HL 249.924
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,641.50 |
| Max. Negotiated Rate |
$3,082.00 |
| Rate for Payer: Aetna Commercial |
$3,015.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,881.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,775.50
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,082.00
|
| Rate for Payer: Health EOS Commercial |
$2,981.50
|
| Rate for Payer: HFN Commercial |
$3,082.00
|
| Rate for Payer: Multiplan Commercial |
$2,680.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,010.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,082.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,641.50
|
| Rate for Payer: Quartz Commercial |
$2,010.00
|
| Rate for Payer: WEA Trust Commercial |
$1,842.50
|
| Rate for Payer: WPS Commercial |
$2,481.34
|
|
|
PLATE LC-DCP 2.4MM 4HL 249.924
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$938.00 |
| Max. Negotiated Rate |
$13,400.00 |
| Rate for Payer: Aetna Commercial |
$3,015.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,881.00
|
| Rate for Payer: Aetna Managed Medicare |
$938.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,177.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,675.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,608.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,775.50
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,082.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,874.66
|
| Rate for Payer: Health EOS Commercial |
$2,981.50
|
| Rate for Payer: HFN Commercial |
$3,082.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,512.50
|
| Rate for Payer: Multiplan Commercial |
$2,680.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,010.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,082.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,641.50
|
| Rate for Payer: Quartz Commercial |
$2,177.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,010.00
|
| Rate for Payer: The Alliance Commercial |
$13,400.00
|
| Rate for Payer: WEA Trust Commercial |
$1,842.50
|
| Rate for Payer: WPS Commercial |
$2,481.34
|
|
|
PLATE LC-DCP 2.4MM 6HL 249.926
|
Facility
|
OP
|
$5,537.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,550.36 |
| Max. Negotiated Rate |
$22,148.00 |
| Rate for Payer: Aetna Commercial |
$4,983.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,761.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,550.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,599.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,768.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,657.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,934.61
|
| Rate for Payer: Cash Price |
$1,661.10
|
| Rate for Payer: Cigna Commercial |
$5,094.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,098.51
|
| Rate for Payer: Health EOS Commercial |
$4,927.93
|
| Rate for Payer: HFN Commercial |
$5,094.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,152.75
|
| Rate for Payer: Multiplan Commercial |
$4,429.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,094.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,713.13
|
| Rate for Payer: Quartz Commercial |
$3,599.05
|
| Rate for Payer: Quartz Medicare Advantage |
$3,322.20
|
| Rate for Payer: The Alliance Commercial |
$22,148.00
|
| Rate for Payer: WEA Trust Commercial |
$3,045.35
|
| Rate for Payer: WPS Commercial |
$4,101.26
|
|
|
PLATE LC-DCP 2.4MM 6HL 249.926
|
Facility
|
IP
|
$5,537.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,713.13 |
| Max. Negotiated Rate |
$5,094.04 |
| Rate for Payer: Aetna Commercial |
$4,983.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,761.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,934.61
|
| Rate for Payer: Cash Price |
$1,661.10
|
| Rate for Payer: Cigna Commercial |
$5,094.04
|
| Rate for Payer: Health EOS Commercial |
$4,927.93
|
| Rate for Payer: HFN Commercial |
$5,094.04
|
| Rate for Payer: Multiplan Commercial |
$4,429.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,094.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,713.13
|
| Rate for Payer: Quartz Commercial |
$3,322.20
|
| Rate for Payer: WEA Trust Commercial |
$3,045.35
|
| Rate for Payer: WPS Commercial |
$4,101.26
|
|
|
PLATE LC-DCP 2.4MM 8HL 249.928
|
Facility
|
IP
|
$3,795.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,859.55 |
| Max. Negotiated Rate |
$3,491.40 |
| Rate for Payer: Aetna Commercial |
$3,415.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,263.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,011.35
|
| Rate for Payer: Cash Price |
$1,138.50
|
| Rate for Payer: Cigna Commercial |
$3,491.40
|
| Rate for Payer: Health EOS Commercial |
$3,377.55
|
| Rate for Payer: HFN Commercial |
$3,491.40
|
| Rate for Payer: Multiplan Commercial |
$3,036.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,277.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,491.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,859.55
|
| Rate for Payer: Quartz Commercial |
$2,277.00
|
| Rate for Payer: WEA Trust Commercial |
$2,087.25
|
| Rate for Payer: WPS Commercial |
$2,810.96
|
|
|
PLATE LC-DCP 2.4MM 8HL 249.928
|
Facility
|
OP
|
$3,795.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,062.60 |
| Max. Negotiated Rate |
$15,180.00 |
| Rate for Payer: Aetna Commercial |
$3,415.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,263.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,062.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,466.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,897.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,821.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,011.35
|
| Rate for Payer: Cash Price |
$1,138.50
|
| Rate for Payer: Cigna Commercial |
$3,491.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,123.68
|
| Rate for Payer: Health EOS Commercial |
$3,377.55
|
| Rate for Payer: HFN Commercial |
$3,491.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,846.25
|
| Rate for Payer: Multiplan Commercial |
$3,036.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,277.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,491.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,859.55
|
| Rate for Payer: Quartz Commercial |
$2,466.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,277.00
|
| Rate for Payer: The Alliance Commercial |
$15,180.00
|
| Rate for Payer: WEA Trust Commercial |
$2,087.25
|
| Rate for Payer: WPS Commercial |
$2,810.96
|
|
|
PLATE LCP 1.5MM 6HL WITH GUIDES 02.114.504S
|
Facility
|
IP
|
$3,694.00
|
|
| Hospital Charge Code |
2966316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,810.06 |
| Max. Negotiated Rate |
$3,398.48 |
| Rate for Payer: Aetna Commercial |
$3,324.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,176.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,957.82
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cigna Commercial |
$3,398.48
|
| Rate for Payer: Health EOS Commercial |
$3,287.66
|
| Rate for Payer: HFN Commercial |
$3,398.48
|
| Rate for Payer: Multiplan Commercial |
$2,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,216.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,398.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,810.06
|
| Rate for Payer: Quartz Commercial |
$2,216.40
|
| Rate for Payer: WEA Trust Commercial |
$2,031.70
|
| Rate for Payer: WPS Commercial |
$2,736.15
|
|
|
PLATE LCP 1.5MM 6HL WITH GUIDES 02.114.504S
|
Facility
|
OP
|
$3,694.00
|
|
| Hospital Charge Code |
2966316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,034.32 |
| Max. Negotiated Rate |
$14,776.00 |
| Rate for Payer: Aetna Commercial |
$3,324.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,176.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,034.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,401.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,847.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,773.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,957.82
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cigna Commercial |
$3,398.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,067.16
|
| Rate for Payer: Health EOS Commercial |
$3,287.66
|
| Rate for Payer: HFN Commercial |
$3,398.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,770.50
|
| Rate for Payer: Multiplan Commercial |
$2,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,216.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,398.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,810.06
|
| Rate for Payer: Quartz Commercial |
$2,401.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,216.40
|
| Rate for Payer: The Alliance Commercial |
$14,776.00
|
| Rate for Payer: WEA Trust Commercial |
$2,031.70
|
| Rate for Payer: WPS Commercial |
$2,736.15
|
|
|
PLATE LCP 2.0 10HL 247.360
|
Facility
|
IP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,091.23 |
| Max. Negotiated Rate |
$2,048.84 |
| Rate for Payer: Aetna Commercial |
$2,004.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,915.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,180.31
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,048.84
|
| Rate for Payer: Health EOS Commercial |
$1,982.03
|
| Rate for Payer: HFN Commercial |
$2,048.84
|
| Rate for Payer: Multiplan Commercial |
$1,781.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,336.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,048.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,091.23
|
| Rate for Payer: Quartz Commercial |
$1,336.20
|
| Rate for Payer: WEA Trust Commercial |
$1,224.85
|
| Rate for Payer: WPS Commercial |
$1,649.54
|
|
|
PLATE LCP 2.0 10HL 247.360
|
Facility
|
OP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$623.56 |
| Max. Negotiated Rate |
$8,908.00 |
| Rate for Payer: Aetna Commercial |
$2,004.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,915.22
|
| Rate for Payer: Aetna Managed Medicare |
$623.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,447.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,113.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,068.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,180.31
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,048.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,246.23
|
| Rate for Payer: Health EOS Commercial |
$1,982.03
|
| Rate for Payer: HFN Commercial |
$2,048.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,670.25
|
| Rate for Payer: Multiplan Commercial |
$1,781.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,336.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,048.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,091.23
|
| Rate for Payer: Quartz Commercial |
$1,447.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,336.20
|
| Rate for Payer: The Alliance Commercial |
$8,908.00
|
| Rate for Payer: WEA Trust Commercial |
$1,224.85
|
| Rate for Payer: WPS Commercial |
$1,649.54
|
|
|
PLATE LCP 2.0 4HL 247.344
|
Facility
|
IP
|
$3,929.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966322
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,925.21 |
| Max. Negotiated Rate |
$3,614.68 |
| Rate for Payer: Aetna Commercial |
$3,536.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,378.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,082.37
|
| Rate for Payer: Cash Price |
$1,178.70
|
| Rate for Payer: Cigna Commercial |
$3,614.68
|
| Rate for Payer: Health EOS Commercial |
$3,496.81
|
| Rate for Payer: HFN Commercial |
$3,614.68
|
| Rate for Payer: Multiplan Commercial |
$3,143.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,357.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,614.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,925.21
|
| Rate for Payer: Quartz Commercial |
$2,357.40
|
| Rate for Payer: WEA Trust Commercial |
$2,160.95
|
| Rate for Payer: WPS Commercial |
$2,910.21
|
|
|
PLATE LCP 2.0 4HL 247.344
|
Facility
|
OP
|
$3,929.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966322
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,100.12 |
| Max. Negotiated Rate |
$15,716.00 |
| Rate for Payer: Aetna Commercial |
$3,536.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,378.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,100.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,553.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,964.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,885.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,082.37
|
| Rate for Payer: Cash Price |
$1,178.70
|
| Rate for Payer: Cigna Commercial |
$3,614.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,198.67
|
| Rate for Payer: Health EOS Commercial |
$3,496.81
|
| Rate for Payer: HFN Commercial |
$3,614.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,946.75
|
| Rate for Payer: Multiplan Commercial |
$3,143.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,357.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,614.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,925.21
|
| Rate for Payer: Quartz Commercial |
$2,553.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,357.40
|
| Rate for Payer: The Alliance Commercial |
$15,716.00
|
| Rate for Payer: WEA Trust Commercial |
$2,160.95
|
| Rate for Payer: WPS Commercial |
$2,910.21
|
|
|
PLATE LCP 2.0 5HL 247.345
|
Facility
|
OP
|
$3,039.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$850.92 |
| Max. Negotiated Rate |
$12,156.00 |
| Rate for Payer: Aetna Commercial |
$2,735.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,613.54
|
| Rate for Payer: Aetna Managed Medicare |
$850.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,975.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,519.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,458.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,610.67
|
| Rate for Payer: Cash Price |
$911.70
|
| Rate for Payer: Cigna Commercial |
$2,795.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,700.62
|
| Rate for Payer: Health EOS Commercial |
$2,704.71
|
| Rate for Payer: HFN Commercial |
$2,795.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,279.25
|
| Rate for Payer: Multiplan Commercial |
$2,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,823.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,795.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,489.11
|
| Rate for Payer: Quartz Commercial |
$1,975.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,823.40
|
| Rate for Payer: The Alliance Commercial |
$12,156.00
|
| Rate for Payer: WEA Trust Commercial |
$1,671.45
|
| Rate for Payer: WPS Commercial |
$2,250.99
|
|
|
PLATE LCP 2.0 5HL 247.345
|
Facility
|
IP
|
$3,039.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,489.11 |
| Max. Negotiated Rate |
$2,795.88 |
| Rate for Payer: Aetna Commercial |
$2,735.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,613.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,610.67
|
| Rate for Payer: Cash Price |
$911.70
|
| Rate for Payer: Cigna Commercial |
$2,795.88
|
| Rate for Payer: Health EOS Commercial |
$2,704.71
|
| Rate for Payer: HFN Commercial |
$2,795.88
|
| Rate for Payer: Multiplan Commercial |
$2,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,823.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,795.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,489.11
|
| Rate for Payer: Quartz Commercial |
$1,823.40
|
| Rate for Payer: WEA Trust Commercial |
$1,671.45
|
| Rate for Payer: WPS Commercial |
$2,250.99
|
|
|
PLATE LCP 2.0 6HL 247.346
|
Facility
|
IP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,091.23 |
| Max. Negotiated Rate |
$2,048.84 |
| Rate for Payer: Aetna Commercial |
$2,004.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,915.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,180.31
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,048.84
|
| Rate for Payer: Health EOS Commercial |
$1,982.03
|
| Rate for Payer: HFN Commercial |
$2,048.84
|
| Rate for Payer: Multiplan Commercial |
$1,781.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,336.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,048.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,091.23
|
| Rate for Payer: Quartz Commercial |
$1,336.20
|
| Rate for Payer: WEA Trust Commercial |
$1,224.85
|
| Rate for Payer: WPS Commercial |
$1,649.54
|
|
|
PLATE LCP 2.0 6HL 247.346
|
Facility
|
OP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$623.56 |
| Max. Negotiated Rate |
$8,908.00 |
| Rate for Payer: Aetna Commercial |
$2,004.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,915.22
|
| Rate for Payer: Aetna Managed Medicare |
$623.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,447.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,113.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,068.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,180.31
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,048.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,246.23
|
| Rate for Payer: Health EOS Commercial |
$1,982.03
|
| Rate for Payer: HFN Commercial |
$2,048.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,670.25
|
| Rate for Payer: Multiplan Commercial |
$1,781.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,336.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,048.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,091.23
|
| Rate for Payer: Quartz Commercial |
$1,447.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,336.20
|
| Rate for Payer: The Alliance Commercial |
$8,908.00
|
| Rate for Payer: WEA Trust Commercial |
$1,224.85
|
| Rate for Payer: WPS Commercial |
$1,649.54
|
|
|
PLATE LCP 2.0 7HL 247.347
|
Facility
|
OP
|
$2,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.48 |
| Max. Negotiated Rate |
$8,564.00 |
| Rate for Payer: Aetna Commercial |
$1,926.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,841.26
|
| Rate for Payer: Aetna Managed Medicare |
$599.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,391.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,070.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,027.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,134.73
|
| Rate for Payer: Cash Price |
$642.30
|
| Rate for Payer: Cigna Commercial |
$1,969.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,198.10
|
| Rate for Payer: Health EOS Commercial |
$1,905.49
|
| Rate for Payer: HFN Commercial |
$1,969.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,605.75
|
| Rate for Payer: Multiplan Commercial |
$1,712.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,284.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,969.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,049.09
|
| Rate for Payer: Quartz Commercial |
$1,391.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,284.60
|
| Rate for Payer: The Alliance Commercial |
$8,564.00
|
| Rate for Payer: WEA Trust Commercial |
$1,177.55
|
| Rate for Payer: WPS Commercial |
$1,585.84
|
|
|
PLATE LCP 2.0 7HL 247.347
|
Facility
|
IP
|
$2,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,049.09 |
| Max. Negotiated Rate |
$1,969.72 |
| Rate for Payer: Aetna Commercial |
$1,926.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,841.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,134.73
|
| Rate for Payer: Cash Price |
$642.30
|
| Rate for Payer: Cigna Commercial |
$1,969.72
|
| Rate for Payer: Health EOS Commercial |
$1,905.49
|
| Rate for Payer: HFN Commercial |
$1,969.72
|
| Rate for Payer: Multiplan Commercial |
$1,712.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,284.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,969.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,049.09
|
| Rate for Payer: Quartz Commercial |
$1,284.60
|
| Rate for Payer: WEA Trust Commercial |
$1,177.55
|
| Rate for Payer: WPS Commercial |
$1,585.84
|
|
|
PLATE LCP 2.0 8HL 247.348
|
Facility
|
IP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,091.23 |
| Max. Negotiated Rate |
$2,048.84 |
| Rate for Payer: Aetna Commercial |
$2,004.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,915.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,180.31
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,048.84
|
| Rate for Payer: Health EOS Commercial |
$1,982.03
|
| Rate for Payer: HFN Commercial |
$2,048.84
|
| Rate for Payer: Multiplan Commercial |
$1,781.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,336.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,048.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,091.23
|
| Rate for Payer: Quartz Commercial |
$1,336.20
|
| Rate for Payer: WEA Trust Commercial |
$1,224.85
|
| Rate for Payer: WPS Commercial |
$1,649.54
|
|
|
PLATE LCP 2.0 8HL 247.348
|
Facility
|
OP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$623.56 |
| Max. Negotiated Rate |
$8,908.00 |
| Rate for Payer: Aetna Commercial |
$2,004.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,915.22
|
| Rate for Payer: Aetna Managed Medicare |
$623.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,447.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,113.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,068.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,180.31
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,048.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,246.23
|
| Rate for Payer: Health EOS Commercial |
$1,982.03
|
| Rate for Payer: HFN Commercial |
$2,048.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,670.25
|
| Rate for Payer: Multiplan Commercial |
$1,781.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,336.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,048.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,091.23
|
| Rate for Payer: Quartz Commercial |
$1,447.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,336.20
|
| Rate for Payer: The Alliance Commercial |
$8,908.00
|
| Rate for Payer: WEA Trust Commercial |
$1,224.85
|
| Rate for Payer: WPS Commercial |
$1,649.54
|
|
|
PLATE LCP ADAPTION 2.0 12HL 247.362
|
Facility
|
OP
|
$4,923.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,378.44 |
| Max. Negotiated Rate |
$19,692.00 |
| Rate for Payer: Aetna Commercial |
$4,430.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,233.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,378.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,199.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,461.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,363.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,609.19
|
| Rate for Payer: Cash Price |
$1,476.90
|
| Rate for Payer: Cigna Commercial |
$4,529.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,754.91
|
| Rate for Payer: Health EOS Commercial |
$4,381.47
|
| Rate for Payer: HFN Commercial |
$4,529.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,692.25
|
| Rate for Payer: Multiplan Commercial |
$3,938.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,953.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,529.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,412.27
|
| Rate for Payer: Quartz Commercial |
$3,199.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,953.80
|
| Rate for Payer: The Alliance Commercial |
$19,692.00
|
| Rate for Payer: WEA Trust Commercial |
$2,707.65
|
| Rate for Payer: WPS Commercial |
$3,646.47
|
|
|
PLATE LCP ADAPTION 2.0 12HL 247.362
|
Facility
|
IP
|
$4,923.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,412.27 |
| Max. Negotiated Rate |
$4,529.16 |
| Rate for Payer: Aetna Commercial |
$4,430.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,233.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,609.19
|
| Rate for Payer: Cash Price |
$1,476.90
|
| Rate for Payer: Cigna Commercial |
$4,529.16
|
| Rate for Payer: Health EOS Commercial |
$4,381.47
|
| Rate for Payer: HFN Commercial |
$4,529.16
|
| Rate for Payer: Multiplan Commercial |
$3,938.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,953.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,529.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,412.27
|
| Rate for Payer: Quartz Commercial |
$2,953.80
|
| Rate for Payer: WEA Trust Commercial |
$2,707.65
|
| Rate for Payer: WPS Commercial |
$3,646.47
|
|
