|
PLATE PROXIMAL TIBIAL PLATLOW BEND LCP 6HL RT 02.124.204
|
Facility
|
OP
|
$6,549.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415315
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,833.72 |
| Max. Negotiated Rate |
$26,196.00 |
| Rate for Payer: Aetna Commercial |
$5,894.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,632.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,833.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,256.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,274.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,143.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,470.97
|
| Rate for Payer: Cash Price |
$1,964.70
|
| Rate for Payer: Cigna Commercial |
$6,025.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,664.82
|
| Rate for Payer: Health EOS Commercial |
$5,828.61
|
| Rate for Payer: HFN Commercial |
$6,025.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,911.75
|
| Rate for Payer: Multiplan Commercial |
$5,239.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,929.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,025.08
|
| Rate for Payer: Quartz Beloit One Network |
$3,209.01
|
| Rate for Payer: Quartz Commercial |
$4,256.85
|
| Rate for Payer: Quartz Medicare Advantage |
$3,929.40
|
| Rate for Payer: The Alliance Commercial |
$26,196.00
|
| Rate for Payer: WEA Trust Commercial |
$3,601.95
|
| Rate for Payer: WPS Commercial |
$4,850.84
|
|
|
PLATE RADIAL HEAD LOCKING 3HL SM CURVATURE 70-0099
|
Facility
|
IP
|
$8,581.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,204.69 |
| Max. Negotiated Rate |
$7,894.52 |
| Rate for Payer: Aetna Commercial |
$7,722.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,379.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,547.93
|
| Rate for Payer: Cash Price |
$2,574.30
|
| Rate for Payer: Cigna Commercial |
$7,894.52
|
| Rate for Payer: Health EOS Commercial |
$7,637.09
|
| Rate for Payer: HFN Commercial |
$7,894.52
|
| Rate for Payer: Multiplan Commercial |
$6,864.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,148.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,894.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,204.69
|
| Rate for Payer: Quartz Commercial |
$5,148.60
|
| Rate for Payer: WEA Trust Commercial |
$4,719.55
|
| Rate for Payer: WPS Commercial |
$6,355.95
|
|
|
PLATE RADIAL HEAD LOCKING 3HL SM CURVATURE 70-0099
|
Facility
|
OP
|
$8,581.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,402.68 |
| Max. Negotiated Rate |
$34,324.00 |
| Rate for Payer: Aetna Commercial |
$7,722.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,379.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,402.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,577.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,290.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,118.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,547.93
|
| Rate for Payer: Cash Price |
$2,574.30
|
| Rate for Payer: Cigna Commercial |
$7,894.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,801.93
|
| Rate for Payer: Health EOS Commercial |
$7,637.09
|
| Rate for Payer: HFN Commercial |
$7,894.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,435.75
|
| Rate for Payer: Multiplan Commercial |
$6,864.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,148.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,894.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,204.69
|
| Rate for Payer: Quartz Commercial |
$5,577.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,148.60
|
| Rate for Payer: The Alliance Commercial |
$34,324.00
|
| Rate for Payer: WEA Trust Commercial |
$4,719.55
|
| Rate for Payer: WPS Commercial |
$6,355.95
|
|
|
PLATE RECONSTRUCTION 5HL 245.15
|
Facility
|
IP
|
$953.00
|
|
| Hospital Charge Code |
2966772
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$466.97 |
| Max. Negotiated Rate |
$876.76 |
| Rate for Payer: Aetna Commercial |
$857.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$819.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$505.09
|
| Rate for Payer: Cash Price |
$285.90
|
| Rate for Payer: Cigna Commercial |
$876.76
|
| Rate for Payer: Health EOS Commercial |
$848.17
|
| Rate for Payer: HFN Commercial |
$876.76
|
| Rate for Payer: Multiplan Commercial |
$762.40
|
| Rate for Payer: NAPHCARE Commercial |
$571.80
|
| Rate for Payer: Preferred Network Access Commercial |
$876.76
|
| Rate for Payer: Quartz Beloit One Network |
$466.97
|
| Rate for Payer: Quartz Commercial |
$571.80
|
| Rate for Payer: WEA Trust Commercial |
$524.15
|
| Rate for Payer: WPS Commercial |
$705.89
|
|
|
PLATE RECONSTRUCTION 5HL 245.15
|
Facility
|
OP
|
$953.00
|
|
| Hospital Charge Code |
2966772
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.84 |
| Max. Negotiated Rate |
$3,812.00 |
| Rate for Payer: Aetna Commercial |
$857.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$819.58
|
| Rate for Payer: Aetna Managed Medicare |
$266.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$619.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$476.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$457.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$505.09
|
| Rate for Payer: Cash Price |
$285.90
|
| Rate for Payer: Cigna Commercial |
$876.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$533.30
|
| Rate for Payer: Health EOS Commercial |
$848.17
|
| Rate for Payer: HFN Commercial |
$876.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$714.75
|
| Rate for Payer: Multiplan Commercial |
$762.40
|
| Rate for Payer: NAPHCARE Commercial |
$571.80
|
| Rate for Payer: Preferred Network Access Commercial |
$876.76
|
| Rate for Payer: Quartz Beloit One Network |
$466.97
|
| Rate for Payer: Quartz Commercial |
$619.45
|
| Rate for Payer: Quartz Medicare Advantage |
$571.80
|
| Rate for Payer: The Alliance Commercial |
$3,812.00
|
| Rate for Payer: WEA Trust Commercial |
$524.15
|
| Rate for Payer: WPS Commercial |
$705.89
|
|
|
PLATE RECONSTRUCTION 6HL 245.16
|
Facility
|
OP
|
$1,862.00
|
|
| Hospital Charge Code |
2966773
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.36 |
| Max. Negotiated Rate |
$7,448.00 |
| Rate for Payer: Aetna Commercial |
$1,675.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,601.32
|
| Rate for Payer: Aetna Managed Medicare |
$521.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,210.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$931.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$893.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$986.86
|
| Rate for Payer: Cash Price |
$558.60
|
| Rate for Payer: Cigna Commercial |
$1,713.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,041.98
|
| Rate for Payer: Health EOS Commercial |
$1,657.18
|
| Rate for Payer: HFN Commercial |
$1,713.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,396.50
|
| Rate for Payer: Multiplan Commercial |
$1,489.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,117.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,713.04
|
| Rate for Payer: Quartz Beloit One Network |
$912.38
|
| Rate for Payer: Quartz Commercial |
$1,210.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,117.20
|
| Rate for Payer: The Alliance Commercial |
$7,448.00
|
| Rate for Payer: WEA Trust Commercial |
$1,024.10
|
| Rate for Payer: WPS Commercial |
$1,379.18
|
|
|
PLATE RECONSTRUCTION 6HL 245.16
|
Facility
|
IP
|
$1,862.00
|
|
| Hospital Charge Code |
2966773
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$912.38 |
| Max. Negotiated Rate |
$1,713.04 |
| Rate for Payer: Aetna Commercial |
$1,675.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,601.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$986.86
|
| Rate for Payer: Cash Price |
$558.60
|
| Rate for Payer: Cigna Commercial |
$1,713.04
|
| Rate for Payer: Health EOS Commercial |
$1,657.18
|
| Rate for Payer: HFN Commercial |
$1,713.04
|
| Rate for Payer: Multiplan Commercial |
$1,489.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,117.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,713.04
|
| Rate for Payer: Quartz Beloit One Network |
$912.38
|
| Rate for Payer: Quartz Commercial |
$1,117.20
|
| Rate for Payer: WEA Trust Commercial |
$1,024.10
|
| Rate for Payer: WPS Commercial |
$1,379.18
|
|
|
PLATE RECONSTRUCTION 7HL 245.17
|
Facility
|
IP
|
$3,380.00
|
|
| Hospital Charge Code |
2966774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,656.20 |
| Max. Negotiated Rate |
$3,109.60 |
| Rate for Payer: Aetna Commercial |
$3,042.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,906.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,791.40
|
| Rate for Payer: Cash Price |
$1,014.00
|
| Rate for Payer: Cigna Commercial |
$3,109.60
|
| Rate for Payer: Health EOS Commercial |
$3,008.20
|
| Rate for Payer: HFN Commercial |
$3,109.60
|
| Rate for Payer: Multiplan Commercial |
$2,704.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,028.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,109.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,656.20
|
| Rate for Payer: Quartz Commercial |
$2,028.00
|
| Rate for Payer: WEA Trust Commercial |
$1,859.00
|
| Rate for Payer: WPS Commercial |
$2,503.57
|
|
|
PLATE RECONSTRUCTION 7HL 245.17
|
Facility
|
OP
|
$3,380.00
|
|
| Hospital Charge Code |
2966774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$946.40 |
| Max. Negotiated Rate |
$13,520.00 |
| Rate for Payer: Aetna Commercial |
$3,042.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,906.80
|
| Rate for Payer: Aetna Managed Medicare |
$946.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,197.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,690.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,622.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,791.40
|
| Rate for Payer: Cash Price |
$1,014.00
|
| Rate for Payer: Cigna Commercial |
$3,109.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,891.45
|
| Rate for Payer: Health EOS Commercial |
$3,008.20
|
| Rate for Payer: HFN Commercial |
$3,109.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,535.00
|
| Rate for Payer: Multiplan Commercial |
$2,704.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,028.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,109.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,656.20
|
| Rate for Payer: Quartz Commercial |
$2,197.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,028.00
|
| Rate for Payer: The Alliance Commercial |
$13,520.00
|
| Rate for Payer: WEA Trust Commercial |
$1,859.00
|
| Rate for Payer: WPS Commercial |
$2,503.57
|
|
|
PLATE RECONSTRUCTION 8HL 245.18
|
Facility
|
OP
|
$4,078.00
|
|
| Hospital Charge Code |
2966775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,141.84 |
| Max. Negotiated Rate |
$16,312.00 |
| Rate for Payer: Aetna Commercial |
$3,670.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,507.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,141.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,650.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,039.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,957.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,161.34
|
| Rate for Payer: Cash Price |
$1,223.40
|
| Rate for Payer: Cigna Commercial |
$3,751.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,282.05
|
| Rate for Payer: Health EOS Commercial |
$3,629.42
|
| Rate for Payer: HFN Commercial |
$3,751.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,058.50
|
| Rate for Payer: Multiplan Commercial |
$3,262.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,446.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,751.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,998.22
|
| Rate for Payer: Quartz Commercial |
$2,650.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,446.80
|
| Rate for Payer: The Alliance Commercial |
$16,312.00
|
| Rate for Payer: WEA Trust Commercial |
$2,242.90
|
| Rate for Payer: WPS Commercial |
$3,020.57
|
|
|
PLATE RECONSTRUCTION 8HL 245.18
|
Facility
|
IP
|
$4,078.00
|
|
| Hospital Charge Code |
2966775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,998.22 |
| Max. Negotiated Rate |
$3,751.76 |
| Rate for Payer: Aetna Commercial |
$3,670.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,507.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,161.34
|
| Rate for Payer: Cash Price |
$1,223.40
|
| Rate for Payer: Cigna Commercial |
$3,751.76
|
| Rate for Payer: Health EOS Commercial |
$3,629.42
|
| Rate for Payer: HFN Commercial |
$3,751.76
|
| Rate for Payer: Multiplan Commercial |
$3,262.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,446.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,751.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,998.22
|
| Rate for Payer: Quartz Commercial |
$2,446.80
|
| Rate for Payer: WEA Trust Commercial |
$2,242.90
|
| Rate for Payer: WPS Commercial |
$3,020.57
|
|
|
PLATE RT CALCANEAL 241.622
|
Facility
|
OP
|
$6,359.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966377
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,780.52 |
| Max. Negotiated Rate |
$25,436.00 |
| Rate for Payer: Aetna Commercial |
$5,723.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,468.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,780.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,133.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,179.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,052.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,370.27
|
| Rate for Payer: Cash Price |
$1,907.70
|
| Rate for Payer: Cigna Commercial |
$5,850.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,558.50
|
| Rate for Payer: Health EOS Commercial |
$5,659.51
|
| Rate for Payer: HFN Commercial |
$5,850.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,769.25
|
| Rate for Payer: Multiplan Commercial |
$5,087.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,815.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,850.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,115.91
|
| Rate for Payer: Quartz Commercial |
$4,133.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,815.40
|
| Rate for Payer: The Alliance Commercial |
$25,436.00
|
| Rate for Payer: WEA Trust Commercial |
$3,497.45
|
| Rate for Payer: WPS Commercial |
$4,710.11
|
|
|
PLATE RT CALCANEAL 241.622
|
Facility
|
IP
|
$6,359.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966377
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,115.91 |
| Max. Negotiated Rate |
$5,850.28 |
| Rate for Payer: Aetna Commercial |
$5,723.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,468.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,370.27
|
| Rate for Payer: Cash Price |
$1,907.70
|
| Rate for Payer: Cigna Commercial |
$5,850.28
|
| Rate for Payer: Health EOS Commercial |
$5,659.51
|
| Rate for Payer: HFN Commercial |
$5,850.28
|
| Rate for Payer: Multiplan Commercial |
$5,087.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,815.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,850.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,115.91
|
| Rate for Payer: Quartz Commercial |
$3,815.40
|
| Rate for Payer: WEA Trust Commercial |
$3,497.45
|
| Rate for Payer: WPS Commercial |
$4,710.11
|
|
|
PLATE SEMI TUBULAR 10HL 222.10
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2966776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$243.04 |
| Max. Negotiated Rate |
$456.32 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$297.60
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
PLATE SEMI TUBULAR 10HL 222.10
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2966776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.88 |
| Max. Negotiated Rate |
$1,984.00 |
| Rate for Payer: Aetna Commercial |
$446.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.56
|
| Rate for Payer: Aetna Managed Medicare |
$138.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$322.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$248.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$238.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.88
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$456.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.56
|
| Rate for Payer: Health EOS Commercial |
$441.44
|
| Rate for Payer: HFN Commercial |
$456.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.00
|
| Rate for Payer: Multiplan Commercial |
$396.80
|
| Rate for Payer: NAPHCARE Commercial |
$297.60
|
| Rate for Payer: Preferred Network Access Commercial |
$456.32
|
| Rate for Payer: Quartz Beloit One Network |
$243.04
|
| Rate for Payer: Quartz Commercial |
$322.40
|
| Rate for Payer: Quartz Medicare Advantage |
$297.60
|
| Rate for Payer: The Alliance Commercial |
$1,984.00
|
| Rate for Payer: WEA Trust Commercial |
$272.80
|
| Rate for Payer: WPS Commercial |
$367.39
|
|
|
PLATE SEMI TUBULAR 2HL 222.02
|
Facility
|
IP
|
$359.00
|
|
| Hospital Charge Code |
2966777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.91 |
| Max. Negotiated Rate |
$330.28 |
| Rate for Payer: Aetna Commercial |
$323.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$308.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.27
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cigna Commercial |
$330.28
|
| Rate for Payer: Health EOS Commercial |
$319.51
|
| Rate for Payer: HFN Commercial |
$330.28
|
| Rate for Payer: Multiplan Commercial |
$287.20
|
| Rate for Payer: NAPHCARE Commercial |
$215.40
|
| Rate for Payer: Preferred Network Access Commercial |
$330.28
|
| Rate for Payer: Quartz Beloit One Network |
$175.91
|
| Rate for Payer: Quartz Commercial |
$215.40
|
| Rate for Payer: WEA Trust Commercial |
$197.45
|
| Rate for Payer: WPS Commercial |
$265.91
|
|
|
PLATE SEMI TUBULAR 2HL 222.02
|
Facility
|
OP
|
$359.00
|
|
| Hospital Charge Code |
2966777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$100.52 |
| Max. Negotiated Rate |
$1,436.00 |
| Rate for Payer: Aetna Commercial |
$323.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$308.74
|
| Rate for Payer: Aetna Managed Medicare |
$100.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$233.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$179.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$172.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.27
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cigna Commercial |
$330.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.90
|
| Rate for Payer: Health EOS Commercial |
$319.51
|
| Rate for Payer: HFN Commercial |
$330.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$269.25
|
| Rate for Payer: Multiplan Commercial |
$287.20
|
| Rate for Payer: NAPHCARE Commercial |
$215.40
|
| Rate for Payer: Preferred Network Access Commercial |
$330.28
|
| Rate for Payer: Quartz Beloit One Network |
$175.91
|
| Rate for Payer: Quartz Commercial |
$233.35
|
| Rate for Payer: Quartz Medicare Advantage |
$215.40
|
| Rate for Payer: The Alliance Commercial |
$1,436.00
|
| Rate for Payer: WEA Trust Commercial |
$197.45
|
| Rate for Payer: WPS Commercial |
$265.91
|
|
|
PLATE SEMI TUBULAR 3HL 222.03
|
Facility
|
IP
|
$373.00
|
|
| Hospital Charge Code |
2966778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$182.77 |
| Max. Negotiated Rate |
$343.16 |
| Rate for Payer: Aetna Commercial |
$335.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.69
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$343.16
|
| Rate for Payer: Health EOS Commercial |
$331.97
|
| Rate for Payer: HFN Commercial |
$343.16
|
| Rate for Payer: Multiplan Commercial |
$298.40
|
| Rate for Payer: NAPHCARE Commercial |
$223.80
|
| Rate for Payer: Preferred Network Access Commercial |
$343.16
|
| Rate for Payer: Quartz Beloit One Network |
$182.77
|
| Rate for Payer: Quartz Commercial |
$223.80
|
| Rate for Payer: WEA Trust Commercial |
$205.15
|
| Rate for Payer: WPS Commercial |
$276.28
|
|
|
PLATE SEMI TUBULAR 3HL 222.03
|
Facility
|
OP
|
$373.00
|
|
| Hospital Charge Code |
2966778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.44 |
| Max. Negotiated Rate |
$1,492.00 |
| Rate for Payer: Aetna Commercial |
$335.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.78
|
| Rate for Payer: Aetna Managed Medicare |
$104.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$242.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$186.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$179.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.69
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$343.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$208.73
|
| Rate for Payer: Health EOS Commercial |
$331.97
|
| Rate for Payer: HFN Commercial |
$343.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$279.75
|
| Rate for Payer: Multiplan Commercial |
$298.40
|
| Rate for Payer: NAPHCARE Commercial |
$223.80
|
| Rate for Payer: Preferred Network Access Commercial |
$343.16
|
| Rate for Payer: Quartz Beloit One Network |
$182.77
|
| Rate for Payer: Quartz Commercial |
$242.45
|
| Rate for Payer: Quartz Medicare Advantage |
$223.80
|
| Rate for Payer: The Alliance Commercial |
$1,492.00
|
| Rate for Payer: WEA Trust Commercial |
$205.15
|
| Rate for Payer: WPS Commercial |
$276.28
|
|
|
PLATE SEMI TUBULAR 4HL 222.04
|
Facility
|
OP
|
$405.00
|
|
| Hospital Charge Code |
2966779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Aetna Managed Medicare |
$113.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$202.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.64
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.75
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$263.25
|
| Rate for Payer: Quartz Medicare Advantage |
$243.00
|
| Rate for Payer: The Alliance Commercial |
$1,620.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
PLATE SEMI TUBULAR 4HL 222.04
|
Facility
|
IP
|
$405.00
|
|
| Hospital Charge Code |
2966779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.45 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$243.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
PLATE SEMI TUBULAR 5HL 222.05
|
Facility
|
OP
|
$422.00
|
|
| Hospital Charge Code |
2966780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$118.16 |
| Max. Negotiated Rate |
$1,688.00 |
| Rate for Payer: Aetna Commercial |
$379.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.92
|
| Rate for Payer: Aetna Managed Medicare |
$118.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$274.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$211.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$202.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.66
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$388.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.15
|
| Rate for Payer: Health EOS Commercial |
$375.58
|
| Rate for Payer: HFN Commercial |
$388.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$316.50
|
| Rate for Payer: Multiplan Commercial |
$337.60
|
| Rate for Payer: NAPHCARE Commercial |
$253.20
|
| Rate for Payer: Preferred Network Access Commercial |
$388.24
|
| Rate for Payer: Quartz Beloit One Network |
$206.78
|
| Rate for Payer: Quartz Commercial |
$274.30
|
| Rate for Payer: Quartz Medicare Advantage |
$253.20
|
| Rate for Payer: The Alliance Commercial |
$1,688.00
|
| Rate for Payer: WEA Trust Commercial |
$232.10
|
| Rate for Payer: WPS Commercial |
$312.58
|
|
|
PLATE SEMI TUBULAR 5HL 222.05
|
Facility
|
IP
|
$422.00
|
|
| Hospital Charge Code |
2966780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.78 |
| Max. Negotiated Rate |
$388.24 |
| Rate for Payer: Aetna Commercial |
$379.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.66
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$388.24
|
| Rate for Payer: Health EOS Commercial |
$375.58
|
| Rate for Payer: HFN Commercial |
$388.24
|
| Rate for Payer: Multiplan Commercial |
$337.60
|
| Rate for Payer: NAPHCARE Commercial |
$253.20
|
| Rate for Payer: Preferred Network Access Commercial |
$388.24
|
| Rate for Payer: Quartz Beloit One Network |
$206.78
|
| Rate for Payer: Quartz Commercial |
$253.20
|
| Rate for Payer: WEA Trust Commercial |
$232.10
|
| Rate for Payer: WPS Commercial |
$312.58
|
|
|
PLATE SEMI TUBULAR 6HL 222.06
|
Facility
|
IP
|
$447.00
|
|
| Hospital Charge Code |
2966781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$219.03 |
| Max. Negotiated Rate |
$411.24 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$268.20
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
PLATE SEMI TUBULAR 6HL 222.06
|
Facility
|
OP
|
$447.00
|
|
| Hospital Charge Code |
2966781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.16 |
| Max. Negotiated Rate |
$1,788.00 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Aetna Managed Medicare |
$125.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$290.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$223.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$214.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.14
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.25
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$290.55
|
| Rate for Payer: Quartz Medicare Advantage |
$268.20
|
| Rate for Payer: The Alliance Commercial |
$1,788.00
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
