|
PLATE MTP RIGHT ORTHOLOC 3Di CROSSCHECK 5820MPX1R
|
Facility
|
IP
|
$14,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458985
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,950.16 |
| Max. Negotiated Rate |
$13,049.28 |
| Rate for Payer: Aetna Commercial |
$12,765.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,198.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,517.52
|
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Cigna Commercial |
$13,049.28
|
| Rate for Payer: Health EOS Commercial |
$12,623.76
|
| Rate for Payer: HFN Commercial |
$13,049.28
|
| Rate for Payer: Multiplan Commercial |
$11,347.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,510.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,049.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,950.16
|
| Rate for Payer: Quartz Commercial |
$8,510.40
|
| Rate for Payer: WEA Trust Commercial |
$7,801.20
|
| Rate for Payer: WPS Commercial |
$10,506.09
|
|
|
PLATE MTP RIGHT ORTHOLOC 3Di CROSSCHECK 5820MPX1R
|
Facility
|
OP
|
$14,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458985
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,971.52 |
| Max. Negotiated Rate |
$56,736.00 |
| Rate for Payer: Aetna Commercial |
$12,765.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,198.24
|
| Rate for Payer: Aetna Managed Medicare |
$3,971.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,219.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,092.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,808.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,517.52
|
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Cigna Commercial |
$13,049.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,937.37
|
| Rate for Payer: Health EOS Commercial |
$12,623.76
|
| Rate for Payer: HFN Commercial |
$13,049.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,638.00
|
| Rate for Payer: Multiplan Commercial |
$11,347.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,510.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,049.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,950.16
|
| Rate for Payer: Quartz Commercial |
$9,219.60
|
| Rate for Payer: Quartz Medicare Advantage |
$8,510.40
|
| Rate for Payer: The Alliance Commercial |
$56,736.00
|
| Rate for Payer: WEA Trust Commercial |
$7,801.20
|
| Rate for Payer: WPS Commercial |
$10,506.09
|
|
|
PLATE NARROW LCP 10HL 224.601
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 10HL 224.601
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 12HL 224.621
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 12HL 224.621
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 4HL 224.541
|
Facility
|
IP
|
$5,040.00
|
|
| Hospital Charge Code |
2966766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,469.60 |
| Max. Negotiated Rate |
$4,636.80 |
| Rate for Payer: Aetna Commercial |
$4,536.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,334.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.20
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna Commercial |
$4,636.80
|
| Rate for Payer: Health EOS Commercial |
$4,485.60
|
| Rate for Payer: HFN Commercial |
$4,636.80
|
| Rate for Payer: Multiplan Commercial |
$4,032.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,636.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.60
|
| Rate for Payer: Quartz Commercial |
$3,024.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.00
|
| Rate for Payer: WPS Commercial |
$3,733.13
|
|
|
PLATE NARROW LCP 4HL 224.541
|
Facility
|
OP
|
$5,040.00
|
|
| Hospital Charge Code |
2966766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.20 |
| Max. Negotiated Rate |
$20,160.00 |
| Rate for Payer: Aetna Commercial |
$4,536.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,334.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.20
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna Commercial |
$4,636.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.38
|
| Rate for Payer: Health EOS Commercial |
$4,485.60
|
| Rate for Payer: HFN Commercial |
$4,636.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.00
|
| Rate for Payer: Multiplan Commercial |
$4,032.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,636.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.60
|
| Rate for Payer: Quartz Commercial |
$3,276.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.00
|
| Rate for Payer: The Alliance Commercial |
$20,160.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.00
|
| Rate for Payer: WPS Commercial |
$3,733.13
|
|
|
PLATE NARROW LCP 5HL 224.551
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 5HL 224.551
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 6HL 224.561
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 6HL 224.561
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 7HL 224.571
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 7HL 224.571
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 8HL 224.581
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 8HL 224.581
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 9HL 224.591
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 9HL 224.591
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NCM SHORT/RIGHT 9 HL 626772
|
Facility
|
OP
|
$6,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5861715
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,881.60 |
| Max. Negotiated Rate |
$26,880.00 |
| Rate for Payer: Aetna Commercial |
$6,048.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,779.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,881.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,368.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,360.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,225.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,561.60
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Cigna Commercial |
$6,182.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,760.51
|
| Rate for Payer: Health EOS Commercial |
$5,980.80
|
| Rate for Payer: HFN Commercial |
$6,182.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,040.00
|
| Rate for Payer: Multiplan Commercial |
$5,376.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,032.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,182.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,292.80
|
| Rate for Payer: Quartz Commercial |
$4,368.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,032.00
|
| Rate for Payer: The Alliance Commercial |
$26,880.00
|
| Rate for Payer: WEA Trust Commercial |
$3,696.00
|
| Rate for Payer: WPS Commercial |
$4,977.50
|
|
|
PLATE NCM SHORT/RIGHT 9 HL 626772
|
Facility
|
IP
|
$6,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5861715
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,292.80 |
| Max. Negotiated Rate |
$6,182.40 |
| Rate for Payer: Aetna Commercial |
$6,048.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,779.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,561.60
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Cigna Commercial |
$6,182.40
|
| Rate for Payer: Health EOS Commercial |
$5,980.80
|
| Rate for Payer: HFN Commercial |
$6,182.40
|
| Rate for Payer: Multiplan Commercial |
$5,376.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,032.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,182.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,292.80
|
| Rate for Payer: Quartz Commercial |
$4,032.00
|
| Rate for Payer: WEA Trust Commercial |
$3,696.00
|
| Rate for Payer: WPS Commercial |
$4,977.50
|
|
|
PLATE OBLIQ LT T 3H 3H 241.931
|
Facility
|
IP
|
$1,514.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$741.86 |
| Max. Negotiated Rate |
$1,392.88 |
| Rate for Payer: Aetna Commercial |
$1,362.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,302.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$802.42
|
| Rate for Payer: Cash Price |
$454.20
|
| Rate for Payer: Cigna Commercial |
$1,392.88
|
| Rate for Payer: Health EOS Commercial |
$1,347.46
|
| Rate for Payer: HFN Commercial |
$1,392.88
|
| Rate for Payer: Multiplan Commercial |
$1,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$908.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,392.88
|
| Rate for Payer: Quartz Beloit One Network |
$741.86
|
| Rate for Payer: Quartz Commercial |
$908.40
|
| Rate for Payer: WEA Trust Commercial |
$832.70
|
| Rate for Payer: WPS Commercial |
$1,121.42
|
|
|
PLATE OBLIQ LT T 3H 3H 241.931
|
Facility
|
OP
|
$1,514.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$423.92 |
| Max. Negotiated Rate |
$6,056.00 |
| Rate for Payer: Aetna Commercial |
$1,362.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,302.04
|
| Rate for Payer: Aetna Managed Medicare |
$423.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$984.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$757.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$726.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$802.42
|
| Rate for Payer: Cash Price |
$454.20
|
| Rate for Payer: Cigna Commercial |
$1,392.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$847.23
|
| Rate for Payer: Health EOS Commercial |
$1,347.46
|
| Rate for Payer: HFN Commercial |
$1,392.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,135.50
|
| Rate for Payer: Multiplan Commercial |
$1,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$908.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,392.88
|
| Rate for Payer: Quartz Beloit One Network |
$741.86
|
| Rate for Payer: Quartz Commercial |
$984.10
|
| Rate for Payer: Quartz Medicare Advantage |
$908.40
|
| Rate for Payer: The Alliance Commercial |
$6,056.00
|
| Rate for Payer: WEA Trust Commercial |
$832.70
|
| Rate for Payer: WPS Commercial |
$1,121.42
|
|
|
PLATE OBLIQ LT T 3H 4H 241.941
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.48 |
| Max. Negotiated Rate |
$6,364.00 |
| Rate for Payer: Aetna Commercial |
$1,431.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,368.26
|
| Rate for Payer: Aetna Managed Medicare |
$445.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,034.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$795.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$763.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$843.23
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,463.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$890.32
|
| Rate for Payer: Health EOS Commercial |
$1,415.99
|
| Rate for Payer: HFN Commercial |
$1,463.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,193.25
|
| Rate for Payer: Multiplan Commercial |
$1,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$954.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,463.72
|
| Rate for Payer: Quartz Beloit One Network |
$779.59
|
| Rate for Payer: Quartz Commercial |
$1,034.15
|
| Rate for Payer: Quartz Medicare Advantage |
$954.60
|
| Rate for Payer: The Alliance Commercial |
$6,364.00
|
| Rate for Payer: WEA Trust Commercial |
$875.05
|
| Rate for Payer: WPS Commercial |
$1,178.45
|
|
|
PLATE OBLIQ LT T 3H 4H 241.941
|
Facility
|
IP
|
$1,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$779.59 |
| Max. Negotiated Rate |
$1,463.72 |
| Rate for Payer: Aetna Commercial |
$1,431.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,368.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$843.23
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,463.72
|
| Rate for Payer: Health EOS Commercial |
$1,415.99
|
| Rate for Payer: HFN Commercial |
$1,463.72
|
| Rate for Payer: Multiplan Commercial |
$1,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$954.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,463.72
|
| Rate for Payer: Quartz Beloit One Network |
$779.59
|
| Rate for Payer: Quartz Commercial |
$954.60
|
| Rate for Payer: WEA Trust Commercial |
$875.05
|
| Rate for Payer: WPS Commercial |
$1,178.45
|
|
|
PLATE OBLIQ LT T 3H 5H 241.951
|
Facility
|
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$808.50 |
| Max. Negotiated Rate |
$1,518.00 |
| Rate for Payer: Aetna Commercial |
$1,485.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,419.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$874.50
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$1,518.00
|
| Rate for Payer: Health EOS Commercial |
$1,468.50
|
| Rate for Payer: HFN Commercial |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,320.00
|
| Rate for Payer: NAPHCARE Commercial |
$990.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,518.00
|
| Rate for Payer: Quartz Beloit One Network |
$808.50
|
| Rate for Payer: Quartz Commercial |
$990.00
|
| Rate for Payer: WEA Trust Commercial |
$907.50
|
| Rate for Payer: WPS Commercial |
$1,222.16
|
|
