|
PLATE OBLIQ LT T 3H 5H 241.951
|
Facility
|
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.00 |
| Max. Negotiated Rate |
$6,600.00 |
| Rate for Payer: Aetna Commercial |
$1,485.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,419.00
|
| Rate for Payer: Aetna Managed Medicare |
$462.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,072.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$825.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$792.00
|
| 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: Dean Health DHI/DHP/ASO |
$923.34
|
| Rate for Payer: Health EOS Commercial |
$1,468.50
|
| Rate for Payer: HFN Commercial |
$1,518.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,237.50
|
| 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 |
$1,072.50
|
| Rate for Payer: Quartz Medicare Advantage |
$990.00
|
| Rate for Payer: The Alliance Commercial |
$6,600.00
|
| Rate for Payer: WEA Trust Commercial |
$907.50
|
| Rate for Payer: WPS Commercial |
$1,222.16
|
|
|
PLATE OBLIQ LT T 3H 7H 241.971
|
Facility
|
OP
|
$1,797.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$503.16 |
| Max. Negotiated Rate |
$7,188.00 |
| Rate for Payer: Aetna Commercial |
$1,617.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,545.42
|
| Rate for Payer: Aetna Managed Medicare |
$503.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,168.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$898.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$862.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$952.41
|
| Rate for Payer: Cash Price |
$539.10
|
| Rate for Payer: Cigna Commercial |
$1,653.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,005.60
|
| Rate for Payer: Health EOS Commercial |
$1,599.33
|
| Rate for Payer: HFN Commercial |
$1,653.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,347.75
|
| Rate for Payer: Multiplan Commercial |
$1,437.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,078.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,653.24
|
| Rate for Payer: Quartz Beloit One Network |
$880.53
|
| Rate for Payer: Quartz Commercial |
$1,168.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,078.20
|
| Rate for Payer: The Alliance Commercial |
$7,188.00
|
| Rate for Payer: WEA Trust Commercial |
$988.35
|
| Rate for Payer: WPS Commercial |
$1,331.04
|
|
|
PLATE OBLIQ LT T 3H 7H 241.971
|
Facility
|
IP
|
$1,797.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$880.53 |
| Max. Negotiated Rate |
$1,653.24 |
| Rate for Payer: Aetna Commercial |
$1,617.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,545.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$952.41
|
| Rate for Payer: Cash Price |
$539.10
|
| Rate for Payer: Cigna Commercial |
$1,653.24
|
| Rate for Payer: Health EOS Commercial |
$1,599.33
|
| Rate for Payer: HFN Commercial |
$1,653.24
|
| Rate for Payer: Multiplan Commercial |
$1,437.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,078.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,653.24
|
| Rate for Payer: Quartz Beloit One Network |
$880.53
|
| Rate for Payer: Quartz Commercial |
$1,078.20
|
| Rate for Payer: WEA Trust Commercial |
$988.35
|
| Rate for Payer: WPS Commercial |
$1,331.04
|
|
|
PLATE OLECRANON 11HOLE LT 70-0308
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4500789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
PLATE OLECRANON 11HOLE LT 70-0308
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4500789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$7,616.00 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: The Alliance Commercial |
$7,616.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
PLATE OLECRANON 15 HOLE LT 70-0310
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595309
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$7,616.00 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: The Alliance Commercial |
$7,616.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
PLATE OLECRANON 15 HOLE LT 70-0310
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595309
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
PLATE OLECRANON 6 HL LT 629346
|
Facility
|
IP
|
$7,151.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3939329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,503.99 |
| Max. Negotiated Rate |
$6,578.92 |
| Rate for Payer: Aetna Commercial |
$6,435.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,149.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,790.03
|
| Rate for Payer: Cash Price |
$2,145.30
|
| Rate for Payer: Cigna Commercial |
$6,578.92
|
| Rate for Payer: Health EOS Commercial |
$6,364.39
|
| Rate for Payer: HFN Commercial |
$6,578.92
|
| Rate for Payer: Multiplan Commercial |
$5,720.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,290.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,578.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,503.99
|
| Rate for Payer: Quartz Commercial |
$4,290.60
|
| Rate for Payer: WEA Trust Commercial |
$3,933.05
|
| Rate for Payer: WPS Commercial |
$5,296.75
|
|
|
PLATE OLECRANON 6 HL LT 629346
|
Facility
|
OP
|
$7,151.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3939329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.28 |
| Max. Negotiated Rate |
$28,604.00 |
| Rate for Payer: Aetna Commercial |
$6,435.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,149.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,002.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,648.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,575.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,432.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,790.03
|
| Rate for Payer: Cash Price |
$2,145.30
|
| Rate for Payer: Cigna Commercial |
$6,578.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,001.70
|
| Rate for Payer: Health EOS Commercial |
$6,364.39
|
| Rate for Payer: HFN Commercial |
$6,578.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,363.25
|
| Rate for Payer: Multiplan Commercial |
$5,720.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,290.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,578.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,503.99
|
| Rate for Payer: Quartz Commercial |
$4,648.15
|
| Rate for Payer: Quartz Medicare Advantage |
$4,290.60
|
| Rate for Payer: The Alliance Commercial |
$28,604.00
|
| Rate for Payer: WEA Trust Commercial |
$3,933.05
|
| Rate for Payer: WPS Commercial |
$5,296.75
|
|
|
PLATE OLECRANON LEFT 2 HOLE
|
Facility
|
OP
|
$8,278.00
|
|
| Hospital Charge Code |
2966374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,317.84 |
| Max. Negotiated Rate |
$33,112.00 |
| Rate for Payer: Aetna Commercial |
$7,450.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,119.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,317.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,380.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,139.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,973.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,387.34
|
| Rate for Payer: Cash Price |
$2,483.40
|
| Rate for Payer: Cigna Commercial |
$7,615.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,632.37
|
| Rate for Payer: Health EOS Commercial |
$7,367.42
|
| Rate for Payer: HFN Commercial |
$7,615.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,208.50
|
| Rate for Payer: Multiplan Commercial |
$6,622.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,966.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,615.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,056.22
|
| Rate for Payer: Quartz Commercial |
$5,380.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,966.80
|
| Rate for Payer: The Alliance Commercial |
$33,112.00
|
| Rate for Payer: WEA Trust Commercial |
$4,552.90
|
| Rate for Payer: WPS Commercial |
$6,131.51
|
|
|
PLATE OLECRANON LEFT 2 HOLE
|
Facility
|
IP
|
$8,278.00
|
|
| Hospital Charge Code |
2966374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,056.22 |
| Max. Negotiated Rate |
$7,615.76 |
| Rate for Payer: Aetna Commercial |
$7,450.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,119.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,387.34
|
| Rate for Payer: Cash Price |
$2,483.40
|
| Rate for Payer: Cigna Commercial |
$7,615.76
|
| Rate for Payer: Health EOS Commercial |
$7,367.42
|
| Rate for Payer: HFN Commercial |
$7,615.76
|
| Rate for Payer: Multiplan Commercial |
$6,622.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,966.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,615.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,056.22
|
| Rate for Payer: Quartz Commercial |
$4,966.80
|
| Rate for Payer: WEA Trust Commercial |
$4,552.90
|
| Rate for Payer: WPS Commercial |
$6,131.51
|
|
|
PLATE OLECRANON PROXIMAL 2.7/3.5 2HL RT 02.107.202S
|
Facility
|
OP
|
$7,339.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3127490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,054.92 |
| Max. Negotiated Rate |
$29,356.00 |
| Rate for Payer: Aetna Commercial |
$6,605.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,311.54
|
| Rate for Payer: Aetna Managed Medicare |
$2,054.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,770.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,669.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,522.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,889.67
|
| Rate for Payer: Cash Price |
$2,201.70
|
| Rate for Payer: Cigna Commercial |
$6,751.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,106.90
|
| Rate for Payer: Health EOS Commercial |
$6,531.71
|
| Rate for Payer: HFN Commercial |
$6,751.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,504.25
|
| Rate for Payer: Multiplan Commercial |
$5,871.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,403.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,751.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,596.11
|
| Rate for Payer: Quartz Commercial |
$4,770.35
|
| Rate for Payer: Quartz Medicare Advantage |
$4,403.40
|
| Rate for Payer: The Alliance Commercial |
$29,356.00
|
| Rate for Payer: WEA Trust Commercial |
$4,036.45
|
| Rate for Payer: WPS Commercial |
$5,436.00
|
|
|
PLATE OLECRANON PROXIMAL 2.7/3.5 2HL RT 02.107.202S
|
Facility
|
IP
|
$7,339.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3127490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,596.11 |
| Max. Negotiated Rate |
$6,751.88 |
| Rate for Payer: Aetna Commercial |
$6,605.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,311.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,889.67
|
| Rate for Payer: Cash Price |
$2,201.70
|
| Rate for Payer: Cigna Commercial |
$6,751.88
|
| Rate for Payer: Health EOS Commercial |
$6,531.71
|
| Rate for Payer: HFN Commercial |
$6,751.88
|
| Rate for Payer: Multiplan Commercial |
$5,871.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,403.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,751.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,596.11
|
| Rate for Payer: Quartz Commercial |
$4,403.40
|
| Rate for Payer: WEA Trust Commercial |
$4,036.45
|
| Rate for Payer: WPS Commercial |
$5,436.00
|
|
|
PLATE PERI. PROXIMAL HUMEROUS 3HL RT 02.123.040
|
Facility
|
IP
|
$10,665.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966375
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,225.85 |
| Max. Negotiated Rate |
$9,811.80 |
| Rate for Payer: Aetna Commercial |
$9,598.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,171.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,652.45
|
| Rate for Payer: Cash Price |
$3,199.50
|
| Rate for Payer: Cigna Commercial |
$9,811.80
|
| Rate for Payer: Health EOS Commercial |
$9,491.85
|
| Rate for Payer: HFN Commercial |
$9,811.80
|
| Rate for Payer: Multiplan Commercial |
$8,532.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,399.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,811.80
|
| Rate for Payer: Quartz Beloit One Network |
$5,225.85
|
| Rate for Payer: Quartz Commercial |
$6,399.00
|
| Rate for Payer: WEA Trust Commercial |
$5,865.75
|
| Rate for Payer: WPS Commercial |
$7,899.57
|
|
|
PLATE PERI. PROXIMAL HUMEROUS 3HL RT 02.123.040
|
Facility
|
OP
|
$10,665.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966375
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,986.20 |
| Max. Negotiated Rate |
$42,660.00 |
| Rate for Payer: Aetna Commercial |
$9,598.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,171.90
|
| Rate for Payer: Aetna Managed Medicare |
$2,986.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,932.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,332.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,119.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,652.45
|
| Rate for Payer: Cash Price |
$3,199.50
|
| Rate for Payer: Cigna Commercial |
$9,811.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,968.13
|
| Rate for Payer: Health EOS Commercial |
$9,491.85
|
| Rate for Payer: HFN Commercial |
$9,811.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,998.75
|
| Rate for Payer: Multiplan Commercial |
$8,532.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,399.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,811.80
|
| Rate for Payer: Quartz Beloit One Network |
$5,225.85
|
| Rate for Payer: Quartz Commercial |
$6,932.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,399.00
|
| Rate for Payer: The Alliance Commercial |
$42,660.00
|
| Rate for Payer: WEA Trust Commercial |
$5,865.75
|
| Rate for Payer: WPS Commercial |
$7,899.57
|
|
|
PLATE POSTERIAL LATERAL DISTAL
|
Facility
|
IP
|
$7,274.00
|
|
| Hospital Charge Code |
2966376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,564.26 |
| Max. Negotiated Rate |
$6,692.08 |
| Rate for Payer: Aetna Commercial |
$6,546.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,255.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,855.22
|
| Rate for Payer: Cash Price |
$2,182.20
|
| Rate for Payer: Cigna Commercial |
$6,692.08
|
| Rate for Payer: Health EOS Commercial |
$6,473.86
|
| Rate for Payer: HFN Commercial |
$6,692.08
|
| Rate for Payer: Multiplan Commercial |
$5,819.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,364.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,692.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,564.26
|
| Rate for Payer: Quartz Commercial |
$4,364.40
|
| Rate for Payer: WEA Trust Commercial |
$4,000.70
|
| Rate for Payer: WPS Commercial |
$5,387.85
|
|
|
PLATE POSTERIAL LATERAL DISTAL
|
Facility
|
OP
|
$7,274.00
|
|
| Hospital Charge Code |
2966376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,036.72 |
| Max. Negotiated Rate |
$29,096.00 |
| Rate for Payer: Aetna Commercial |
$6,546.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,255.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,036.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,728.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,637.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,491.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,855.22
|
| Rate for Payer: Cash Price |
$2,182.20
|
| Rate for Payer: Cigna Commercial |
$6,692.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,070.53
|
| Rate for Payer: Health EOS Commercial |
$6,473.86
|
| Rate for Payer: HFN Commercial |
$6,692.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,455.50
|
| Rate for Payer: Multiplan Commercial |
$5,819.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,364.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,692.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,564.26
|
| Rate for Payer: Quartz Commercial |
$4,728.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,364.40
|
| Rate for Payer: The Alliance Commercial |
$29,096.00
|
| Rate for Payer: WEA Trust Commercial |
$4,000.70
|
| Rate for Payer: WPS Commercial |
$5,387.85
|
|
|
PLATE POSTERIOR LATERAL 3 HOLE RT 629263
|
Facility
|
OP
|
$6,761.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5599675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,893.08 |
| Max. Negotiated Rate |
$27,044.00 |
| Rate for Payer: Aetna Commercial |
$6,084.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,814.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,893.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,394.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,380.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,245.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,583.33
|
| Rate for Payer: Cash Price |
$2,028.30
|
| Rate for Payer: Cigna Commercial |
$6,220.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,783.46
|
| Rate for Payer: Health EOS Commercial |
$6,017.29
|
| Rate for Payer: HFN Commercial |
$6,220.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,070.75
|
| Rate for Payer: Multiplan Commercial |
$5,408.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,056.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,220.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,312.89
|
| Rate for Payer: Quartz Commercial |
$4,394.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,056.60
|
| Rate for Payer: The Alliance Commercial |
$27,044.00
|
| Rate for Payer: WEA Trust Commercial |
$3,718.55
|
| Rate for Payer: WPS Commercial |
$5,007.87
|
|
|
PLATE POSTERIOR LATERAL 3 HOLE RT 629263
|
Facility
|
IP
|
$6,761.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5599675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,312.89 |
| Max. Negotiated Rate |
$6,220.12 |
| Rate for Payer: Aetna Commercial |
$6,084.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,814.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,583.33
|
| Rate for Payer: Cash Price |
$2,028.30
|
| Rate for Payer: Cigna Commercial |
$6,220.12
|
| Rate for Payer: Health EOS Commercial |
$6,017.29
|
| Rate for Payer: HFN Commercial |
$6,220.12
|
| Rate for Payer: Multiplan Commercial |
$5,408.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,056.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,220.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,312.89
|
| Rate for Payer: Quartz Commercial |
$4,056.60
|
| Rate for Payer: WEA Trust Commercial |
$3,718.55
|
| Rate for Payer: WPS Commercial |
$5,007.87
|
|
|
PLATE POSTERIOR LATERAL 4 HOLE LT 629244
|
Facility
|
OP
|
$2,547.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4006580
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$713.16 |
| Max. Negotiated Rate |
$10,188.00 |
| Rate for Payer: Aetna Commercial |
$2,292.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,190.42
|
| Rate for Payer: Aetna Managed Medicare |
$713.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,655.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,273.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,222.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,349.91
|
| Rate for Payer: Cash Price |
$764.10
|
| Rate for Payer: Cigna Commercial |
$2,343.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,425.30
|
| Rate for Payer: Health EOS Commercial |
$2,266.83
|
| Rate for Payer: HFN Commercial |
$2,343.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,910.25
|
| Rate for Payer: Multiplan Commercial |
$2,037.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,528.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,343.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,248.03
|
| Rate for Payer: Quartz Commercial |
$1,655.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,528.20
|
| Rate for Payer: The Alliance Commercial |
$10,188.00
|
| Rate for Payer: WEA Trust Commercial |
$1,400.85
|
| Rate for Payer: WPS Commercial |
$1,886.56
|
|
|
PLATE POSTERIOR LATERAL 4 HOLE LT 629244
|
Facility
|
IP
|
$2,547.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4006580
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.03 |
| Max. Negotiated Rate |
$2,343.24 |
| Rate for Payer: Aetna Commercial |
$2,292.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,190.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,349.91
|
| Rate for Payer: Cash Price |
$764.10
|
| Rate for Payer: Cigna Commercial |
$2,343.24
|
| Rate for Payer: Health EOS Commercial |
$2,266.83
|
| Rate for Payer: HFN Commercial |
$2,343.24
|
| Rate for Payer: Multiplan Commercial |
$2,037.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,528.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,343.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,248.03
|
| Rate for Payer: Quartz Commercial |
$1,528.20
|
| Rate for Payer: WEA Trust Commercial |
$1,400.85
|
| Rate for Payer: WPS Commercial |
$1,886.56
|
|
|
PLATE POSTERIOR LATERAL 6 HOLE LT 629246
|
Facility
|
OP
|
$7,018.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4006558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,965.04 |
| Max. Negotiated Rate |
$28,072.00 |
| Rate for Payer: Aetna Commercial |
$6,316.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,035.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,965.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,561.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,509.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,368.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,719.54
|
| Rate for Payer: Cash Price |
$2,105.40
|
| Rate for Payer: Cigna Commercial |
$6,456.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,927.27
|
| Rate for Payer: Health EOS Commercial |
$6,246.02
|
| Rate for Payer: HFN Commercial |
$6,456.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,263.50
|
| Rate for Payer: Multiplan Commercial |
$5,614.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,210.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,456.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,438.82
|
| Rate for Payer: Quartz Commercial |
$4,561.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,210.80
|
| Rate for Payer: The Alliance Commercial |
$28,072.00
|
| Rate for Payer: WEA Trust Commercial |
$3,859.90
|
| Rate for Payer: WPS Commercial |
$5,198.23
|
|
|
PLATE POSTERIOR LATERAL 6 HOLE LT 629246
|
Facility
|
IP
|
$7,018.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4006558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,438.82 |
| Max. Negotiated Rate |
$6,456.56 |
| Rate for Payer: Aetna Commercial |
$6,316.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,035.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,719.54
|
| Rate for Payer: Cash Price |
$2,105.40
|
| Rate for Payer: Cigna Commercial |
$6,456.56
|
| Rate for Payer: Health EOS Commercial |
$6,246.02
|
| Rate for Payer: HFN Commercial |
$6,456.56
|
| Rate for Payer: Multiplan Commercial |
$5,614.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,210.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,456.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,438.82
|
| Rate for Payer: Quartz Commercial |
$4,210.80
|
| Rate for Payer: WEA Trust Commercial |
$3,859.90
|
| Rate for Payer: WPS Commercial |
$5,198.23
|
|
|
PLATE PRE-CONTOURED 12 HOLE RIBFIX BLUE 76-2602
|
Facility
|
IP
|
$8,996.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5627636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,408.04 |
| Max. Negotiated Rate |
$8,276.32 |
| Rate for Payer: Aetna Commercial |
$8,096.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,736.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,767.88
|
| Rate for Payer: Cash Price |
$2,698.80
|
| Rate for Payer: Cigna Commercial |
$8,276.32
|
| Rate for Payer: Health EOS Commercial |
$8,006.44
|
| Rate for Payer: HFN Commercial |
$8,276.32
|
| Rate for Payer: Multiplan Commercial |
$7,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,397.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,276.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,408.04
|
| Rate for Payer: Quartz Commercial |
$5,397.60
|
| Rate for Payer: WEA Trust Commercial |
$4,947.80
|
| Rate for Payer: WPS Commercial |
$6,663.34
|
|
|
PLATE PRE-CONTOURED 12 HOLE RIBFIX BLUE 76-2602
|
Facility
|
OP
|
$8,996.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5627636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,518.88 |
| Max. Negotiated Rate |
$35,984.00 |
| Rate for Payer: Aetna Commercial |
$8,096.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,736.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,518.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,847.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,498.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,318.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,767.88
|
| Rate for Payer: Cash Price |
$2,698.80
|
| Rate for Payer: Cigna Commercial |
$8,276.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,034.16
|
| Rate for Payer: Health EOS Commercial |
$8,006.44
|
| Rate for Payer: HFN Commercial |
$8,276.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,747.00
|
| Rate for Payer: Multiplan Commercial |
$7,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,397.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,276.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,408.04
|
| Rate for Payer: Quartz Commercial |
$5,847.40
|
| Rate for Payer: Quartz Medicare Advantage |
$5,397.60
|
| Rate for Payer: The Alliance Commercial |
$35,984.00
|
| Rate for Payer: WEA Trust Commercial |
$4,947.80
|
| Rate for Payer: WPS Commercial |
$6,663.34
|
|
