|
PLATE 10H RT PROX/TIB 240.042
|
Facility
|
OP
|
$4,732.00
|
|
| Hospital Charge Code |
2966667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,377.96 |
| Max. Negotiated Rate |
$4,527.58 |
| Rate for Payer: Aetna Commercial |
$4,429.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,232.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,377.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,198.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,460.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,362.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,608.28
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,527.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,754.02
|
| Rate for Payer: Health EOS Commercial |
$4,379.94
|
| Rate for Payer: HFN Commercial |
$4,527.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,690.96
|
| Rate for Payer: Multiplan Commercial |
$3,937.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,952.77
|
| Rate for Payer: Preferred Network Access Commercial |
$4,527.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,411.43
|
| Rate for Payer: Quartz Commercial |
$3,198.83
|
| Rate for Payer: Quartz Medicare Advantage |
$2,952.77
|
| Rate for Payer: The Alliance Commercial |
$2,460.64
|
| Rate for Payer: WEA Trust Commercial |
$2,706.70
|
| Rate for Payer: WPS Commercial |
$3,645.06
|
|
|
PLATE 12H 3.5 LCP 223.621
|
Facility
|
IP
|
$1,732.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$882.63 |
| Max. Negotiated Rate |
$1,657.18 |
| Rate for Payer: Aetna Commercial |
$1,621.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,549.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.68
|
| Rate for Payer: Cash Price |
$519.60
|
| Rate for Payer: Cigna Commercial |
$1,657.18
|
| Rate for Payer: Health EOS Commercial |
$1,603.14
|
| Rate for Payer: HFN Commercial |
$1,657.18
|
| Rate for Payer: Multiplan Commercial |
$1,441.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,657.18
|
| Rate for Payer: Quartz Beloit One Network |
$882.63
|
| Rate for Payer: Quartz Commercial |
$1,080.77
|
| Rate for Payer: WEA Trust Commercial |
$990.70
|
| Rate for Payer: WPS Commercial |
$1,334.16
|
|
|
PLATE 12H 3.5 LCP 223.621
|
Facility
|
OP
|
$1,732.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$504.36 |
| Max. Negotiated Rate |
$1,657.18 |
| Rate for Payer: Aetna Commercial |
$1,621.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,549.10
|
| Rate for Payer: Aetna Managed Medicare |
$504.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,170.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$900.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$864.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.68
|
| Rate for Payer: Cash Price |
$519.60
|
| Rate for Payer: Cigna Commercial |
$1,657.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,008.02
|
| Rate for Payer: Health EOS Commercial |
$1,603.14
|
| Rate for Payer: HFN Commercial |
$1,657.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,350.96
|
| Rate for Payer: Multiplan Commercial |
$1,441.02
|
| Rate for Payer: NAPHCARE Commercial |
$1,080.77
|
| Rate for Payer: Preferred Network Access Commercial |
$1,657.18
|
| Rate for Payer: Quartz Beloit One Network |
$882.63
|
| Rate for Payer: Quartz Commercial |
$1,170.83
|
| Rate for Payer: Quartz Medicare Advantage |
$1,080.77
|
| Rate for Payer: The Alliance Commercial |
$900.64
|
| Rate for Payer: WEA Trust Commercial |
$990.70
|
| Rate for Payer: WPS Commercial |
$1,334.16
|
|
|
PLATE 12H 3.5 LCP RECO 245.121
|
Facility
|
OP
|
$2,641.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$769.06 |
| Max. Negotiated Rate |
$2,526.91 |
| Rate for Payer: Aetna Commercial |
$2,471.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,362.11
|
| Rate for Payer: Aetna Managed Medicare |
$769.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,785.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,373.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,318.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,455.72
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,526.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,537.06
|
| Rate for Payer: Health EOS Commercial |
$2,444.51
|
| Rate for Payer: HFN Commercial |
$2,526.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,059.98
|
| Rate for Payer: Multiplan Commercial |
$2,197.31
|
| Rate for Payer: NAPHCARE Commercial |
$1,647.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,526.91
|
| Rate for Payer: Quartz Beloit One Network |
$1,345.85
|
| Rate for Payer: Quartz Commercial |
$1,785.32
|
| Rate for Payer: Quartz Medicare Advantage |
$1,647.98
|
| Rate for Payer: The Alliance Commercial |
$1,373.32
|
| Rate for Payer: WEA Trust Commercial |
$1,510.65
|
| Rate for Payer: WPS Commercial |
$2,034.36
|
|
|
PLATE 12H 3.5 LCP RECO 245.121
|
Facility
|
IP
|
$2,641.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,345.85 |
| Max. Negotiated Rate |
$2,526.91 |
| Rate for Payer: Aetna Commercial |
$2,471.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,362.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,455.72
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,526.91
|
| Rate for Payer: Health EOS Commercial |
$2,444.51
|
| Rate for Payer: HFN Commercial |
$2,526.91
|
| Rate for Payer: Multiplan Commercial |
$2,197.31
|
| Rate for Payer: Preferred Network Access Commercial |
$2,526.91
|
| Rate for Payer: Quartz Beloit One Network |
$1,345.85
|
| Rate for Payer: Quartz Commercial |
$1,647.98
|
| Rate for Payer: WEA Trust Commercial |
$1,510.65
|
| Rate for Payer: WPS Commercial |
$2,034.36
|
|
|
PLATE 12H LT CONDYLAR 222.663
|
Facility
|
IP
|
$4,449.00
|
|
| Hospital Charge Code |
2966671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,267.21 |
| Max. Negotiated Rate |
$4,256.80 |
| Rate for Payer: Aetna Commercial |
$4,164.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,979.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,452.29
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,256.80
|
| Rate for Payer: Health EOS Commercial |
$4,117.99
|
| Rate for Payer: HFN Commercial |
$4,256.80
|
| Rate for Payer: Multiplan Commercial |
$3,701.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,256.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,267.21
|
| Rate for Payer: Quartz Commercial |
$2,776.18
|
| Rate for Payer: WEA Trust Commercial |
$2,544.83
|
| Rate for Payer: WPS Commercial |
$3,427.06
|
|
|
PLATE 12H LT CONDYLAR 222.663
|
Facility
|
OP
|
$4,449.00
|
|
| Hospital Charge Code |
2966671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,295.55 |
| Max. Negotiated Rate |
$4,256.80 |
| Rate for Payer: Aetna Commercial |
$4,164.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,979.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,295.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,007.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,313.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,220.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,452.29
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,256.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,589.32
|
| Rate for Payer: Health EOS Commercial |
$4,117.99
|
| Rate for Payer: HFN Commercial |
$4,256.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,470.22
|
| Rate for Payer: Multiplan Commercial |
$3,701.57
|
| Rate for Payer: NAPHCARE Commercial |
$2,776.18
|
| Rate for Payer: Preferred Network Access Commercial |
$4,256.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,267.21
|
| Rate for Payer: Quartz Commercial |
$3,007.52
|
| Rate for Payer: Quartz Medicare Advantage |
$2,776.18
|
| Rate for Payer: The Alliance Commercial |
$2,313.48
|
| Rate for Payer: WEA Trust Commercial |
$2,544.83
|
| Rate for Payer: WPS Commercial |
$3,427.06
|
|
|
PLATE 12H LT PROX/TIB 240.045
|
Facility
|
IP
|
$4,787.00
|
|
| Hospital Charge Code |
2966672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.46 |
| Max. Negotiated Rate |
$4,580.20 |
| Rate for Payer: Aetna Commercial |
$4,480.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.59
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,580.20
|
| Rate for Payer: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.46
|
| Rate for Payer: Quartz Commercial |
$2,987.09
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
|
PLATE 12H LT PROX/TIB 240.045
|
Facility
|
OP
|
$4,787.00
|
|
| Hospital Charge Code |
2966672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.97 |
| Max. Negotiated Rate |
$4,580.20 |
| Rate for Payer: Aetna Commercial |
$4,480.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.49
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,236.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.59
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,580.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,786.03
|
| Rate for Payer: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.86
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,987.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.46
|
| Rate for Payer: Quartz Commercial |
$3,236.01
|
| Rate for Payer: Quartz Medicare Advantage |
$2,987.09
|
| Rate for Payer: The Alliance Commercial |
$2,489.24
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
|
PLATE 12 HOLE CURVED BROAD
|
Facility
|
IP
|
$6,880.00
|
|
| Hospital Charge Code |
2966318
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,506.05 |
| Max. Negotiated Rate |
$6,582.78 |
| Rate for Payer: Aetna Commercial |
$6,439.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,153.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,792.26
|
| Rate for Payer: Cash Price |
$2,064.00
|
| Rate for Payer: Cigna Commercial |
$6,582.78
|
| Rate for Payer: Health EOS Commercial |
$6,368.13
|
| Rate for Payer: HFN Commercial |
$6,582.78
|
| Rate for Payer: Multiplan Commercial |
$5,724.16
|
| Rate for Payer: Preferred Network Access Commercial |
$6,582.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,506.05
|
| Rate for Payer: Quartz Commercial |
$4,293.12
|
| Rate for Payer: WEA Trust Commercial |
$3,935.36
|
| Rate for Payer: WPS Commercial |
$5,299.66
|
|
|
PLATE 12 HOLE CURVED BROAD
|
Facility
|
OP
|
$6,880.00
|
|
| Hospital Charge Code |
2966318
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,003.46 |
| Max. Negotiated Rate |
$6,582.78 |
| Rate for Payer: Aetna Commercial |
$6,439.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,153.47
|
| Rate for Payer: Aetna Managed Medicare |
$2,003.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,650.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,577.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,434.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,792.26
|
| Rate for Payer: Cash Price |
$2,064.00
|
| Rate for Payer: Cigna Commercial |
$6,582.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,004.16
|
| Rate for Payer: Health EOS Commercial |
$6,368.13
|
| Rate for Payer: HFN Commercial |
$6,582.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,366.40
|
| Rate for Payer: Multiplan Commercial |
$5,724.16
|
| Rate for Payer: NAPHCARE Commercial |
$4,293.12
|
| Rate for Payer: Preferred Network Access Commercial |
$6,582.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,506.05
|
| Rate for Payer: Quartz Commercial |
$4,650.88
|
| Rate for Payer: Quartz Medicare Advantage |
$4,293.12
|
| Rate for Payer: The Alliance Commercial |
$3,577.60
|
| Rate for Payer: WEA Trust Commercial |
$3,935.36
|
| Rate for Payer: WPS Commercial |
$5,299.66
|
|
|
PLATE 12H RT CONDYLAR 02.001.322
|
Facility
|
IP
|
$4,449.00
|
|
| Hospital Charge Code |
2966670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,267.21 |
| Max. Negotiated Rate |
$4,256.80 |
| Rate for Payer: Aetna Commercial |
$4,164.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,979.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,452.29
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,256.80
|
| Rate for Payer: Health EOS Commercial |
$4,117.99
|
| Rate for Payer: HFN Commercial |
$4,256.80
|
| Rate for Payer: Multiplan Commercial |
$3,701.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,256.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,267.21
|
| Rate for Payer: Quartz Commercial |
$2,776.18
|
| Rate for Payer: WEA Trust Commercial |
$2,544.83
|
| Rate for Payer: WPS Commercial |
$3,427.06
|
|
|
PLATE 12H RT CONDYLAR 02.001.322
|
Facility
|
OP
|
$4,449.00
|
|
| Hospital Charge Code |
2966670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,295.55 |
| Max. Negotiated Rate |
$4,256.80 |
| Rate for Payer: Aetna Commercial |
$4,164.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,979.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,295.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,007.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,313.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,220.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,452.29
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,256.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,589.32
|
| Rate for Payer: Health EOS Commercial |
$4,117.99
|
| Rate for Payer: HFN Commercial |
$4,256.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,470.22
|
| Rate for Payer: Multiplan Commercial |
$3,701.57
|
| Rate for Payer: NAPHCARE Commercial |
$2,776.18
|
| Rate for Payer: Preferred Network Access Commercial |
$4,256.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,267.21
|
| Rate for Payer: Quartz Commercial |
$3,007.52
|
| Rate for Payer: Quartz Medicare Advantage |
$2,776.18
|
| Rate for Payer: The Alliance Commercial |
$2,313.48
|
| Rate for Payer: WEA Trust Commercial |
$2,544.83
|
| Rate for Payer: WPS Commercial |
$3,427.06
|
|
|
PLATE 12H RT PROX/TIB 240.044
|
Facility
|
OP
|
$4,787.00
|
|
| Hospital Charge Code |
2966673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.97 |
| Max. Negotiated Rate |
$4,580.20 |
| Rate for Payer: Aetna Commercial |
$4,480.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.49
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,236.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.59
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,580.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,786.03
|
| Rate for Payer: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.86
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,987.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.46
|
| Rate for Payer: Quartz Commercial |
$3,236.01
|
| Rate for Payer: Quartz Medicare Advantage |
$2,987.09
|
| Rate for Payer: The Alliance Commercial |
$2,489.24
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
|
PLATE 12H RT PROX/TIB 240.044
|
Facility
|
IP
|
$4,787.00
|
|
| Hospital Charge Code |
2966673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.46 |
| Max. Negotiated Rate |
$4,580.20 |
| Rate for Payer: Aetna Commercial |
$4,480.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.59
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,580.20
|
| Rate for Payer: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.46
|
| Rate for Payer: Quartz Commercial |
$2,987.09
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
|
PLATE 1/3 TUB 10HL 241.401
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966643
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$403.60 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$494.21
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
PLATE 1/3 TUB 10HL 241.401
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966643
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.63 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Aetna Managed Medicare |
$230.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$535.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$411.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$395.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$460.94
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$617.76
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: NAPHCARE Commercial |
$494.21
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$535.39
|
| Rate for Payer: Quartz Medicare Advantage |
$494.21
|
| Rate for Payer: The Alliance Commercial |
$411.84
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
PLATE 1/3 TUB 10HL STRYKER 626680
|
Facility
|
OP
|
$3,646.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,061.72 |
| Max. Negotiated Rate |
$3,488.49 |
| Rate for Payer: Aetna Commercial |
$3,412.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,260.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,061.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,464.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,895.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,820.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,009.68
|
| Rate for Payer: Cash Price |
$1,093.80
|
| Rate for Payer: Cigna Commercial |
$3,488.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,121.97
|
| Rate for Payer: Health EOS Commercial |
$3,374.74
|
| Rate for Payer: HFN Commercial |
$3,488.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,843.88
|
| Rate for Payer: Multiplan Commercial |
$3,033.47
|
| Rate for Payer: NAPHCARE Commercial |
$2,275.10
|
| Rate for Payer: Preferred Network Access Commercial |
$3,488.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,858.00
|
| Rate for Payer: Quartz Commercial |
$2,464.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,275.10
|
| Rate for Payer: The Alliance Commercial |
$1,895.92
|
| Rate for Payer: WEA Trust Commercial |
$2,085.51
|
| Rate for Payer: WPS Commercial |
$2,808.51
|
|
|
PLATE 1/3 TUB 10HL STRYKER 626680
|
Facility
|
IP
|
$3,646.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,858.00 |
| Max. Negotiated Rate |
$3,488.49 |
| Rate for Payer: Aetna Commercial |
$3,412.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,260.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,009.68
|
| Rate for Payer: Cash Price |
$1,093.80
|
| Rate for Payer: Cigna Commercial |
$3,488.49
|
| Rate for Payer: Health EOS Commercial |
$3,374.74
|
| Rate for Payer: HFN Commercial |
$3,488.49
|
| Rate for Payer: Multiplan Commercial |
$3,033.47
|
| Rate for Payer: Preferred Network Access Commercial |
$3,488.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,858.00
|
| Rate for Payer: Quartz Commercial |
$2,275.10
|
| Rate for Payer: WEA Trust Commercial |
$2,085.51
|
| Rate for Payer: WPS Commercial |
$2,808.51
|
|
|
PLATE 1/3 TUB 12HL 241.421
|
Facility
|
IP
|
$822.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.89 |
| Max. Negotiated Rate |
$786.49 |
| Rate for Payer: Aetna Commercial |
$769.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.09
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$786.49
|
| Rate for Payer: Health EOS Commercial |
$760.84
|
| Rate for Payer: HFN Commercial |
$786.49
|
| Rate for Payer: Multiplan Commercial |
$683.90
|
| Rate for Payer: Preferred Network Access Commercial |
$786.49
|
| Rate for Payer: Quartz Beloit One Network |
$418.89
|
| Rate for Payer: Quartz Commercial |
$512.93
|
| Rate for Payer: WEA Trust Commercial |
$470.18
|
| Rate for Payer: WPS Commercial |
$633.19
|
|
|
PLATE 1/3 TUB 12HL 241.421
|
Facility
|
OP
|
$822.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$239.37 |
| Max. Negotiated Rate |
$786.49 |
| Rate for Payer: Aetna Commercial |
$769.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.20
|
| Rate for Payer: Aetna Managed Medicare |
$239.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$555.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$427.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$410.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.09
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$786.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$478.40
|
| Rate for Payer: Health EOS Commercial |
$760.84
|
| Rate for Payer: HFN Commercial |
$786.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$641.16
|
| Rate for Payer: Multiplan Commercial |
$683.90
|
| Rate for Payer: NAPHCARE Commercial |
$512.93
|
| Rate for Payer: Preferred Network Access Commercial |
$786.49
|
| Rate for Payer: Quartz Beloit One Network |
$418.89
|
| Rate for Payer: Quartz Commercial |
$555.67
|
| Rate for Payer: Quartz Medicare Advantage |
$512.93
|
| Rate for Payer: The Alliance Commercial |
$427.44
|
| Rate for Payer: WEA Trust Commercial |
$470.18
|
| Rate for Payer: WPS Commercial |
$633.19
|
|
|
PLATE 1/3 TUB 5HL 241.351
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$375.58 |
| Max. Negotiated Rate |
$705.16 |
| Rate for Payer: Aetna Commercial |
$689.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$659.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$406.23
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$705.16
|
| Rate for Payer: Health EOS Commercial |
$682.17
|
| Rate for Payer: HFN Commercial |
$705.16
|
| Rate for Payer: Multiplan Commercial |
$613.18
|
| Rate for Payer: Preferred Network Access Commercial |
$705.16
|
| Rate for Payer: Quartz Beloit One Network |
$375.58
|
| Rate for Payer: Quartz Commercial |
$459.89
|
| Rate for Payer: WEA Trust Commercial |
$421.56
|
| Rate for Payer: WPS Commercial |
$567.71
|
|
|
PLATE 1/3 TUB 5HL 241.351
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.61 |
| Max. Negotiated Rate |
$705.16 |
| Rate for Payer: Aetna Commercial |
$689.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$659.17
|
| Rate for Payer: Aetna Managed Medicare |
$214.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$498.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$383.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$367.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$406.23
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$705.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$428.93
|
| Rate for Payer: Health EOS Commercial |
$682.17
|
| Rate for Payer: HFN Commercial |
$705.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.86
|
| Rate for Payer: Multiplan Commercial |
$613.18
|
| Rate for Payer: NAPHCARE Commercial |
$459.89
|
| Rate for Payer: Preferred Network Access Commercial |
$705.16
|
| Rate for Payer: Quartz Beloit One Network |
$375.58
|
| Rate for Payer: Quartz Commercial |
$498.21
|
| Rate for Payer: Quartz Medicare Advantage |
$459.89
|
| Rate for Payer: The Alliance Commercial |
$383.24
|
| Rate for Payer: WEA Trust Commercial |
$421.56
|
| Rate for Payer: WPS Commercial |
$567.71
|
|
|
PLATE 1/3 TUB 6HL 241.361
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.61 |
| Max. Negotiated Rate |
$705.16 |
| Rate for Payer: Aetna Commercial |
$689.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$659.17
|
| Rate for Payer: Aetna Managed Medicare |
$214.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$498.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$383.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$367.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$406.23
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$705.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$428.93
|
| Rate for Payer: Health EOS Commercial |
$682.17
|
| Rate for Payer: HFN Commercial |
$705.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.86
|
| Rate for Payer: Multiplan Commercial |
$613.18
|
| Rate for Payer: NAPHCARE Commercial |
$459.89
|
| Rate for Payer: Preferred Network Access Commercial |
$705.16
|
| Rate for Payer: Quartz Beloit One Network |
$375.58
|
| Rate for Payer: Quartz Commercial |
$498.21
|
| Rate for Payer: Quartz Medicare Advantage |
$459.89
|
| Rate for Payer: The Alliance Commercial |
$383.24
|
| Rate for Payer: WEA Trust Commercial |
$421.56
|
| Rate for Payer: WPS Commercial |
$567.71
|
|
|
PLATE 1/3 TUB 6HL 241.361
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$375.58 |
| Max. Negotiated Rate |
$705.16 |
| Rate for Payer: Aetna Commercial |
$689.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$659.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$406.23
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$705.16
|
| Rate for Payer: Health EOS Commercial |
$682.17
|
| Rate for Payer: HFN Commercial |
$705.16
|
| Rate for Payer: Multiplan Commercial |
$613.18
|
| Rate for Payer: Preferred Network Access Commercial |
$705.16
|
| Rate for Payer: Quartz Beloit One Network |
$375.58
|
| Rate for Payer: Quartz Commercial |
$459.89
|
| Rate for Payer: WEA Trust Commercial |
$421.56
|
| Rate for Payer: WPS Commercial |
$567.71
|
|
