|
PLATE 1/3 TUBULAR 4HL 241.34
|
Facility
|
IP
|
$991.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966647
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.01 |
| Max. Negotiated Rate |
$948.19 |
| Rate for Payer: Aetna Commercial |
$927.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$886.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.24
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$948.19
|
| Rate for Payer: Health EOS Commercial |
$917.27
|
| Rate for Payer: HFN Commercial |
$948.19
|
| Rate for Payer: Multiplan Commercial |
$824.51
|
| Rate for Payer: Preferred Network Access Commercial |
$948.19
|
| Rate for Payer: Quartz Beloit One Network |
$505.01
|
| Rate for Payer: Quartz Commercial |
$618.38
|
| Rate for Payer: WEA Trust Commercial |
$566.85
|
| Rate for Payer: WPS Commercial |
$763.37
|
|
|
PLATE 1/3 TUBULAR 5HL 241.35
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$131.62 |
| Max. Negotiated Rate |
$432.47 |
| Rate for Payer: Aetna Commercial |
$423.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.27
|
| Rate for Payer: Aetna Managed Medicare |
$131.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$305.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$235.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$225.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.14
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$432.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.06
|
| Rate for Payer: Health EOS Commercial |
$418.37
|
| Rate for Payer: HFN Commercial |
$432.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$352.56
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: NAPHCARE Commercial |
$282.05
|
| Rate for Payer: Preferred Network Access Commercial |
$432.47
|
| Rate for Payer: Quartz Beloit One Network |
$230.34
|
| Rate for Payer: Quartz Commercial |
$305.55
|
| Rate for Payer: Quartz Medicare Advantage |
$282.05
|
| Rate for Payer: The Alliance Commercial |
$235.04
|
| Rate for Payer: WEA Trust Commercial |
$258.54
|
| Rate for Payer: WPS Commercial |
$348.18
|
|
|
PLATE 1/3 TUBULAR 5HL 241.35
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.34 |
| Max. Negotiated Rate |
$432.47 |
| Rate for Payer: Aetna Commercial |
$423.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.14
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$432.47
|
| Rate for Payer: Health EOS Commercial |
$418.37
|
| Rate for Payer: HFN Commercial |
$432.47
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: Preferred Network Access Commercial |
$432.47
|
| Rate for Payer: Quartz Beloit One Network |
$230.34
|
| Rate for Payer: Quartz Commercial |
$282.05
|
| Rate for Payer: WEA Trust Commercial |
$258.54
|
| Rate for Payer: WPS Commercial |
$348.18
|
|
|
PLATE 1/3 TUBULAR 6HL 241.36
|
Facility
|
OP
|
$1,117.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966650
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$325.27 |
| Max. Negotiated Rate |
$1,068.75 |
| Rate for Payer: Aetna Commercial |
$1,045.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$999.04
|
| Rate for Payer: Aetna Managed Medicare |
$325.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$755.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$580.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$557.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$615.69
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,068.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$650.09
|
| Rate for Payer: Health EOS Commercial |
$1,033.90
|
| Rate for Payer: HFN Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$871.26
|
| Rate for Payer: Multiplan Commercial |
$929.34
|
| Rate for Payer: NAPHCARE Commercial |
$697.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,068.75
|
| Rate for Payer: Quartz Beloit One Network |
$569.22
|
| Rate for Payer: Quartz Commercial |
$755.09
|
| Rate for Payer: Quartz Medicare Advantage |
$697.01
|
| Rate for Payer: The Alliance Commercial |
$580.84
|
| Rate for Payer: WEA Trust Commercial |
$638.92
|
| Rate for Payer: WPS Commercial |
$860.43
|
|
|
PLATE 1/3 TUBULAR 6HL 241.36
|
Facility
|
IP
|
$1,117.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966650
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$569.22 |
| Max. Negotiated Rate |
$1,068.75 |
| Rate for Payer: Aetna Commercial |
$1,045.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$999.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$615.69
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,068.75
|
| Rate for Payer: Health EOS Commercial |
$1,033.90
|
| Rate for Payer: HFN Commercial |
$1,068.75
|
| Rate for Payer: Multiplan Commercial |
$929.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,068.75
|
| Rate for Payer: Quartz Beloit One Network |
$569.22
|
| Rate for Payer: Quartz Commercial |
$697.01
|
| Rate for Payer: WEA Trust Commercial |
$638.92
|
| Rate for Payer: WPS Commercial |
$860.43
|
|
|
PLATE 1/3 TUBULAR 7HL 241.37
|
Facility
|
OP
|
$1,064.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$309.84 |
| Max. Negotiated Rate |
$1,018.04 |
| Rate for Payer: Aetna Commercial |
$995.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$951.64
|
| Rate for Payer: Aetna Managed Medicare |
$309.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$719.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$553.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$531.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$586.48
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: Cigna Commercial |
$1,018.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$619.25
|
| Rate for Payer: Health EOS Commercial |
$984.84
|
| Rate for Payer: HFN Commercial |
$1,018.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$829.92
|
| Rate for Payer: Multiplan Commercial |
$885.25
|
| Rate for Payer: NAPHCARE Commercial |
$663.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,018.04
|
| Rate for Payer: Quartz Beloit One Network |
$542.21
|
| Rate for Payer: Quartz Commercial |
$719.26
|
| Rate for Payer: Quartz Medicare Advantage |
$663.94
|
| Rate for Payer: The Alliance Commercial |
$553.28
|
| Rate for Payer: WEA Trust Commercial |
$608.61
|
| Rate for Payer: WPS Commercial |
$819.60
|
|
|
PLATE 1/3 TUBULAR 7HL 241.37
|
Facility
|
IP
|
$1,064.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$542.21 |
| Max. Negotiated Rate |
$1,018.04 |
| Rate for Payer: Aetna Commercial |
$995.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$951.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$586.48
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: Cigna Commercial |
$1,018.04
|
| Rate for Payer: Health EOS Commercial |
$984.84
|
| Rate for Payer: HFN Commercial |
$1,018.04
|
| Rate for Payer: Multiplan Commercial |
$885.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,018.04
|
| Rate for Payer: Quartz Beloit One Network |
$542.21
|
| Rate for Payer: Quartz Commercial |
$663.94
|
| Rate for Payer: WEA Trust Commercial |
$608.61
|
| Rate for Payer: WPS Commercial |
$819.60
|
|
|
PLATE 1/3 TUBULAR 8HL 241.38
|
Facility
|
IP
|
$1,064.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$542.21 |
| Max. Negotiated Rate |
$1,018.04 |
| Rate for Payer: Aetna Commercial |
$995.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$951.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$586.48
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: Cigna Commercial |
$1,018.04
|
| Rate for Payer: Health EOS Commercial |
$984.84
|
| Rate for Payer: HFN Commercial |
$1,018.04
|
| Rate for Payer: Multiplan Commercial |
$885.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,018.04
|
| Rate for Payer: Quartz Beloit One Network |
$542.21
|
| Rate for Payer: Quartz Commercial |
$663.94
|
| Rate for Payer: WEA Trust Commercial |
$608.61
|
| Rate for Payer: WPS Commercial |
$819.60
|
|
|
PLATE 1/3 TUBULAR 8HL 241.38
|
Facility
|
OP
|
$1,064.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$309.84 |
| Max. Negotiated Rate |
$1,018.04 |
| Rate for Payer: Aetna Commercial |
$995.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$951.64
|
| Rate for Payer: Aetna Managed Medicare |
$309.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$719.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$553.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$531.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$586.48
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: Cigna Commercial |
$1,018.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$619.25
|
| Rate for Payer: Health EOS Commercial |
$984.84
|
| Rate for Payer: HFN Commercial |
$1,018.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$829.92
|
| Rate for Payer: Multiplan Commercial |
$885.25
|
| Rate for Payer: NAPHCARE Commercial |
$663.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,018.04
|
| Rate for Payer: Quartz Beloit One Network |
$542.21
|
| Rate for Payer: Quartz Commercial |
$719.26
|
| Rate for Payer: Quartz Medicare Advantage |
$663.94
|
| Rate for Payer: The Alliance Commercial |
$553.28
|
| Rate for Payer: WEA Trust Commercial |
$608.61
|
| Rate for Payer: WPS Commercial |
$819.60
|
|
|
PLATE 1/3 TUBULAR 9HL 241.39
|
Facility
|
OP
|
$983.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5547452
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$286.25 |
| Max. Negotiated Rate |
$940.53 |
| Rate for Payer: Aetna Commercial |
$920.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$879.20
|
| Rate for Payer: Aetna Managed Medicare |
$286.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$664.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$511.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$490.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$541.83
|
| Rate for Payer: Cash Price |
$294.90
|
| Rate for Payer: Cigna Commercial |
$940.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$572.11
|
| Rate for Payer: Health EOS Commercial |
$909.86
|
| Rate for Payer: HFN Commercial |
$940.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$766.74
|
| Rate for Payer: Multiplan Commercial |
$817.86
|
| Rate for Payer: NAPHCARE Commercial |
$613.39
|
| Rate for Payer: Preferred Network Access Commercial |
$940.53
|
| Rate for Payer: Quartz Beloit One Network |
$500.94
|
| Rate for Payer: Quartz Commercial |
$664.51
|
| Rate for Payer: Quartz Medicare Advantage |
$613.39
|
| Rate for Payer: The Alliance Commercial |
$511.16
|
| Rate for Payer: WEA Trust Commercial |
$562.28
|
| Rate for Payer: WPS Commercial |
$757.20
|
|
|
PLATE 1/3 TUBULAR 9HL 241.39
|
Facility
|
IP
|
$983.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5547452
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$500.94 |
| Max. Negotiated Rate |
$940.53 |
| Rate for Payer: Aetna Commercial |
$920.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$879.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$541.83
|
| Rate for Payer: Cash Price |
$294.90
|
| Rate for Payer: Cigna Commercial |
$940.53
|
| Rate for Payer: Health EOS Commercial |
$909.86
|
| Rate for Payer: HFN Commercial |
$940.53
|
| Rate for Payer: Multiplan Commercial |
$817.86
|
| Rate for Payer: Preferred Network Access Commercial |
$940.53
|
| Rate for Payer: Quartz Beloit One Network |
$500.94
|
| Rate for Payer: Quartz Commercial |
$613.39
|
| Rate for Payer: WEA Trust Commercial |
$562.28
|
| Rate for Payer: WPS Commercial |
$757.20
|
|
|
PLATE 14H 3.5 LCP 223.641
|
Facility
|
IP
|
$2,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,320.37 |
| Max. Negotiated Rate |
$2,479.07 |
| Rate for Payer: Aetna Commercial |
$2,425.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,317.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.16
|
| Rate for Payer: Cash Price |
$777.30
|
| Rate for Payer: Cigna Commercial |
$2,479.07
|
| Rate for Payer: Health EOS Commercial |
$2,398.23
|
| Rate for Payer: HFN Commercial |
$2,479.07
|
| Rate for Payer: Multiplan Commercial |
$2,155.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,479.07
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.37
|
| Rate for Payer: Quartz Commercial |
$1,616.78
|
| Rate for Payer: WEA Trust Commercial |
$1,482.05
|
| Rate for Payer: WPS Commercial |
$1,995.85
|
|
|
PLATE 14H 3.5 LCP 223.641
|
Facility
|
OP
|
$2,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$754.50 |
| Max. Negotiated Rate |
$2,479.07 |
| Rate for Payer: Aetna Commercial |
$2,425.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,317.39
|
| Rate for Payer: Aetna Managed Medicare |
$754.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,751.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,347.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,293.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.16
|
| Rate for Payer: Cash Price |
$777.30
|
| Rate for Payer: Cigna Commercial |
$2,479.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,507.96
|
| Rate for Payer: Health EOS Commercial |
$2,398.23
|
| Rate for Payer: HFN Commercial |
$2,479.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,020.98
|
| Rate for Payer: Multiplan Commercial |
$2,155.71
|
| Rate for Payer: NAPHCARE Commercial |
$1,616.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,479.07
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.37
|
| Rate for Payer: Quartz Commercial |
$1,751.52
|
| Rate for Payer: Quartz Medicare Advantage |
$1,616.78
|
| Rate for Payer: The Alliance Commercial |
$1,347.32
|
| Rate for Payer: WEA Trust Commercial |
$1,482.05
|
| Rate for Payer: WPS Commercial |
$1,995.85
|
|
|
PLATE 14H LT CONDYLAR 222.665
|
Facility
|
OP
|
$4,836.00
|
|
| Hospital Charge Code |
2966676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,408.24 |
| Max. Negotiated Rate |
$4,627.08 |
| Rate for Payer: Aetna Commercial |
$4,526.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,408.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,269.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,514.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,414.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.60
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,627.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.55
|
| Rate for Payer: Health EOS Commercial |
$4,476.20
|
| Rate for Payer: HFN Commercial |
$4,627.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,772.08
|
| Rate for Payer: Multiplan Commercial |
$4,023.55
|
| Rate for Payer: NAPHCARE Commercial |
$3,017.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.43
|
| Rate for Payer: Quartz Commercial |
$3,269.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,017.66
|
| Rate for Payer: The Alliance Commercial |
$2,514.72
|
| Rate for Payer: WEA Trust Commercial |
$2,766.19
|
| Rate for Payer: WPS Commercial |
$3,725.17
|
|
|
PLATE 14H LT CONDYLAR 222.665
|
Facility
|
IP
|
$4,836.00
|
|
| Hospital Charge Code |
2966676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.43 |
| Max. Negotiated Rate |
$4,627.08 |
| Rate for Payer: Aetna Commercial |
$4,526.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.60
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,627.08
|
| Rate for Payer: Health EOS Commercial |
$4,476.20
|
| Rate for Payer: HFN Commercial |
$4,627.08
|
| Rate for Payer: Multiplan Commercial |
$4,023.55
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.43
|
| Rate for Payer: Quartz Commercial |
$3,017.66
|
| Rate for Payer: WEA Trust Commercial |
$2,766.19
|
| Rate for Payer: WPS Commercial |
$3,725.17
|
|
|
PLATE 14H LT PROX/TIB 240.047
|
Facility
|
IP
|
$6,958.00
|
|
| Hospital Charge Code |
2966677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,545.80 |
| Max. Negotiated Rate |
$6,657.41 |
| Rate for Payer: Aetna Commercial |
$6,512.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,223.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,835.25
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,657.41
|
| Rate for Payer: Health EOS Commercial |
$6,440.32
|
| Rate for Payer: HFN Commercial |
$6,657.41
|
| Rate for Payer: Multiplan Commercial |
$5,789.06
|
| Rate for Payer: Preferred Network Access Commercial |
$6,657.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.80
|
| Rate for Payer: Quartz Commercial |
$4,341.79
|
| Rate for Payer: WEA Trust Commercial |
$3,979.98
|
| Rate for Payer: WPS Commercial |
$5,359.75
|
|
|
PLATE 14H LT PROX/TIB 240.047
|
Facility
|
OP
|
$6,958.00
|
|
| Hospital Charge Code |
2966677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,026.17 |
| Max. Negotiated Rate |
$6,657.41 |
| Rate for Payer: Aetna Commercial |
$6,512.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,223.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,026.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,703.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,618.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,473.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,835.25
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,657.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,049.56
|
| Rate for Payer: Health EOS Commercial |
$6,440.32
|
| Rate for Payer: HFN Commercial |
$6,657.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,427.24
|
| Rate for Payer: Multiplan Commercial |
$5,789.06
|
| Rate for Payer: NAPHCARE Commercial |
$4,341.79
|
| Rate for Payer: Preferred Network Access Commercial |
$6,657.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.80
|
| Rate for Payer: Quartz Commercial |
$4,703.61
|
| Rate for Payer: Quartz Medicare Advantage |
$4,341.79
|
| Rate for Payer: The Alliance Commercial |
$3,618.16
|
| Rate for Payer: WEA Trust Commercial |
$3,979.98
|
| Rate for Payer: WPS Commercial |
$5,359.75
|
|
|
PLATE 14H RT CONDYLAR 222.664
|
Facility
|
OP
|
$4,836.00
|
|
| Hospital Charge Code |
2966675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,408.24 |
| Max. Negotiated Rate |
$4,627.08 |
| Rate for Payer: Aetna Commercial |
$4,526.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,408.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,269.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,514.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,414.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.60
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,627.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.55
|
| Rate for Payer: Health EOS Commercial |
$4,476.20
|
| Rate for Payer: HFN Commercial |
$4,627.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,772.08
|
| Rate for Payer: Multiplan Commercial |
$4,023.55
|
| Rate for Payer: NAPHCARE Commercial |
$3,017.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.43
|
| Rate for Payer: Quartz Commercial |
$3,269.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,017.66
|
| Rate for Payer: The Alliance Commercial |
$2,514.72
|
| Rate for Payer: WEA Trust Commercial |
$2,766.19
|
| Rate for Payer: WPS Commercial |
$3,725.17
|
|
|
PLATE 14H RT CONDYLAR 222.664
|
Facility
|
IP
|
$4,836.00
|
|
| Hospital Charge Code |
2966675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.43 |
| Max. Negotiated Rate |
$4,627.08 |
| Rate for Payer: Aetna Commercial |
$4,526.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.60
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,627.08
|
| Rate for Payer: Health EOS Commercial |
$4,476.20
|
| Rate for Payer: HFN Commercial |
$4,627.08
|
| Rate for Payer: Multiplan Commercial |
$4,023.55
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.43
|
| Rate for Payer: Quartz Commercial |
$3,017.66
|
| Rate for Payer: WEA Trust Commercial |
$2,766.19
|
| Rate for Payer: WPS Commercial |
$3,725.17
|
|
|
PLATE 14H RT PROX/TIB 240.046
|
Facility
|
IP
|
$6,958.00
|
|
| Hospital Charge Code |
2966678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,545.80 |
| Max. Negotiated Rate |
$6,657.41 |
| Rate for Payer: Aetna Commercial |
$6,512.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,223.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,835.25
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,657.41
|
| Rate for Payer: Health EOS Commercial |
$6,440.32
|
| Rate for Payer: HFN Commercial |
$6,657.41
|
| Rate for Payer: Multiplan Commercial |
$5,789.06
|
| Rate for Payer: Preferred Network Access Commercial |
$6,657.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.80
|
| Rate for Payer: Quartz Commercial |
$4,341.79
|
| Rate for Payer: WEA Trust Commercial |
$3,979.98
|
| Rate for Payer: WPS Commercial |
$5,359.75
|
|
|
PLATE 14H RT PROX/TIB 240.046
|
Facility
|
OP
|
$6,958.00
|
|
| Hospital Charge Code |
2966678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,026.17 |
| Max. Negotiated Rate |
$6,657.41 |
| Rate for Payer: Aetna Commercial |
$6,512.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,223.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,026.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,703.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,618.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,473.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,835.25
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,657.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,049.56
|
| Rate for Payer: Health EOS Commercial |
$6,440.32
|
| Rate for Payer: HFN Commercial |
$6,657.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,427.24
|
| Rate for Payer: Multiplan Commercial |
$5,789.06
|
| Rate for Payer: NAPHCARE Commercial |
$4,341.79
|
| Rate for Payer: Preferred Network Access Commercial |
$6,657.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.80
|
| Rate for Payer: Quartz Commercial |
$4,703.61
|
| Rate for Payer: Quartz Medicare Advantage |
$4,341.79
|
| Rate for Payer: The Alliance Commercial |
$3,618.16
|
| Rate for Payer: WEA Trust Commercial |
$3,979.98
|
| Rate for Payer: WPS Commercial |
$5,359.75
|
|
|
PLATE 1/4 TUBULAR 3HL 242.03
|
Facility
|
IP
|
$434.00
|
|
| Hospital Charge Code |
2966656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.17 |
| Max. Negotiated Rate |
$415.25 |
| Rate for Payer: Aetna Commercial |
$406.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.22
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$415.25
|
| Rate for Payer: Health EOS Commercial |
$401.71
|
| Rate for Payer: HFN Commercial |
$415.25
|
| Rate for Payer: Multiplan Commercial |
$361.09
|
| Rate for Payer: Preferred Network Access Commercial |
$415.25
|
| Rate for Payer: Quartz Beloit One Network |
$221.17
|
| Rate for Payer: Quartz Commercial |
$270.82
|
| Rate for Payer: WEA Trust Commercial |
$248.25
|
| Rate for Payer: WPS Commercial |
$334.31
|
|
|
PLATE 1/4 TUBULAR 3HL 242.03
|
Facility
|
OP
|
$434.00
|
|
| Hospital Charge Code |
2966656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.38 |
| Max. Negotiated Rate |
$415.25 |
| Rate for Payer: Aetna Commercial |
$406.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.17
|
| Rate for Payer: Aetna Managed Medicare |
$126.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$293.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$225.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$216.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.22
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$415.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.59
|
| Rate for Payer: Health EOS Commercial |
$401.71
|
| Rate for Payer: HFN Commercial |
$415.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$338.52
|
| Rate for Payer: Multiplan Commercial |
$361.09
|
| Rate for Payer: NAPHCARE Commercial |
$270.82
|
| Rate for Payer: Preferred Network Access Commercial |
$415.25
|
| Rate for Payer: Quartz Beloit One Network |
$221.17
|
| Rate for Payer: Quartz Commercial |
$293.38
|
| Rate for Payer: Quartz Medicare Advantage |
$270.82
|
| Rate for Payer: The Alliance Commercial |
$225.68
|
| Rate for Payer: WEA Trust Commercial |
$248.25
|
| Rate for Payer: WPS Commercial |
$334.31
|
|
|
PLATE 1/4 TUBULAR 4HL 242.04
|
Facility
|
OP
|
$978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$284.79 |
| Max. Negotiated Rate |
$935.75 |
| Rate for Payer: Aetna Commercial |
$915.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$874.72
|
| Rate for Payer: Aetna Managed Medicare |
$284.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$661.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$508.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$488.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$539.07
|
| Rate for Payer: Cash Price |
$293.40
|
| Rate for Payer: Cigna Commercial |
$935.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$569.20
|
| Rate for Payer: Health EOS Commercial |
$905.24
|
| Rate for Payer: HFN Commercial |
$935.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$762.84
|
| Rate for Payer: Multiplan Commercial |
$813.70
|
| Rate for Payer: NAPHCARE Commercial |
$610.27
|
| Rate for Payer: Preferred Network Access Commercial |
$935.75
|
| Rate for Payer: Quartz Beloit One Network |
$498.39
|
| Rate for Payer: Quartz Commercial |
$661.13
|
| Rate for Payer: Quartz Medicare Advantage |
$610.27
|
| Rate for Payer: The Alliance Commercial |
$508.56
|
| Rate for Payer: WEA Trust Commercial |
$559.42
|
| Rate for Payer: WPS Commercial |
$753.35
|
|
|
PLATE 1/4 TUBULAR 4HL 242.04
|
Facility
|
IP
|
$978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$498.39 |
| Max. Negotiated Rate |
$935.75 |
| Rate for Payer: Aetna Commercial |
$915.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$874.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$539.07
|
| Rate for Payer: Cash Price |
$293.40
|
| Rate for Payer: Cigna Commercial |
$935.75
|
| Rate for Payer: Health EOS Commercial |
$905.24
|
| Rate for Payer: HFN Commercial |
$935.75
|
| Rate for Payer: Multiplan Commercial |
$813.70
|
| Rate for Payer: Preferred Network Access Commercial |
$935.75
|
| Rate for Payer: Quartz Beloit One Network |
$498.39
|
| Rate for Payer: Quartz Commercial |
$610.27
|
| Rate for Payer: WEA Trust Commercial |
$559.42
|
| Rate for Payer: WPS Commercial |
$753.35
|
|
