|
PLATE TIBIA 3.5MM LCP POST/MEDIAL/PROX 1HL 02.120.701
|
Facility
|
IP
|
$6,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6173129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,145.31 |
| Max. Negotiated Rate |
$5,905.48 |
| Rate for Payer: Aetna Commercial |
$5,777.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,520.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,402.07
|
| Rate for Payer: Cash Price |
$1,925.70
|
| Rate for Payer: Cigna Commercial |
$5,905.48
|
| Rate for Payer: Health EOS Commercial |
$5,712.91
|
| Rate for Payer: HFN Commercial |
$5,905.48
|
| Rate for Payer: Multiplan Commercial |
$5,135.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,851.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,905.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,145.31
|
| Rate for Payer: Quartz Commercial |
$3,851.40
|
| Rate for Payer: WEA Trust Commercial |
$3,530.45
|
| Rate for Payer: WPS Commercial |
$4,754.55
|
|
|
PLATE TIBIA 3.5MM LCP POST/MEDIAL/PROX 1HL 02.120.701
|
Facility
|
OP
|
$6,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6173129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,797.32 |
| Max. Negotiated Rate |
$25,676.00 |
| Rate for Payer: Aetna Commercial |
$5,777.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,520.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,797.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,172.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,209.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,081.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,402.07
|
| Rate for Payer: Cash Price |
$1,925.70
|
| Rate for Payer: Cigna Commercial |
$5,905.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,592.07
|
| Rate for Payer: Health EOS Commercial |
$5,712.91
|
| Rate for Payer: HFN Commercial |
$5,905.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,814.25
|
| Rate for Payer: Multiplan Commercial |
$5,135.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,851.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,905.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,145.31
|
| Rate for Payer: Quartz Commercial |
$4,172.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,851.40
|
| Rate for Payer: The Alliance Commercial |
$25,676.00
|
| Rate for Payer: WEA Trust Commercial |
$3,530.45
|
| Rate for Payer: WPS Commercial |
$4,754.55
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 3 5950-37-01
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 3 5950-37-01
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 4 5950-037-02
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 4 5950-037-02
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 5 5950-47-01
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 5 5950-47-01
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 6 5950-47-02
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 6 5950-47-02
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 7 5950-57-01
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 7 5950-57-01
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 8 5950-57-02
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TIBIAL MIS NEXGEN SZ 8 5950-57-02
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
PLATE TWO HOLE SS AR-8958-01S
|
Facility
|
IP
|
$6,463.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,166.87 |
| Max. Negotiated Rate |
$5,945.96 |
| Rate for Payer: Aetna Commercial |
$5,816.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,558.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,425.39
|
| Rate for Payer: Cash Price |
$1,938.90
|
| Rate for Payer: Cigna Commercial |
$5,945.96
|
| Rate for Payer: Health EOS Commercial |
$5,752.07
|
| Rate for Payer: HFN Commercial |
$5,945.96
|
| Rate for Payer: Multiplan Commercial |
$5,170.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,877.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,945.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,166.87
|
| Rate for Payer: Quartz Commercial |
$3,877.80
|
| Rate for Payer: WEA Trust Commercial |
$3,554.65
|
| Rate for Payer: WPS Commercial |
$4,787.14
|
|
|
PLATE TWO HOLE SS AR-8958-01S
|
Facility
|
OP
|
$6,463.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,809.64 |
| Max. Negotiated Rate |
$25,852.00 |
| Rate for Payer: Aetna Commercial |
$5,816.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,558.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,809.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,200.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,231.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,102.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,425.39
|
| Rate for Payer: Cash Price |
$1,938.90
|
| Rate for Payer: Cigna Commercial |
$5,945.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,616.69
|
| Rate for Payer: Health EOS Commercial |
$5,752.07
|
| Rate for Payer: HFN Commercial |
$5,945.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,847.25
|
| Rate for Payer: Multiplan Commercial |
$5,170.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,877.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,945.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,166.87
|
| Rate for Payer: Quartz Commercial |
$4,200.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,877.80
|
| Rate for Payer: The Alliance Commercial |
$25,852.00
|
| Rate for Payer: WEA Trust Commercial |
$3,554.65
|
| Rate for Payer: WPS Commercial |
$4,787.14
|
|
|
PLATE ULNA OSTEOTOMY 2.7MM 8 HOLE 02.111.901
|
Facility
|
OP
|
$9,974.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4494346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.72 |
| Max. Negotiated Rate |
$39,896.00 |
| Rate for Payer: Aetna Commercial |
$8,976.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,577.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,483.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,987.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,286.22
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,176.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,581.45
|
| Rate for Payer: Health EOS Commercial |
$8,876.86
|
| Rate for Payer: HFN Commercial |
$9,176.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,480.50
|
| Rate for Payer: Multiplan Commercial |
$7,979.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,984.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,176.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,887.26
|
| Rate for Payer: Quartz Commercial |
$6,483.10
|
| Rate for Payer: Quartz Medicare Advantage |
$5,984.40
|
| Rate for Payer: The Alliance Commercial |
$39,896.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.70
|
| Rate for Payer: WPS Commercial |
$7,387.74
|
|
|
PLATE ULNA OSTEOTOMY 2.7MM 8 HOLE 02.111.901
|
Facility
|
IP
|
$9,974.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4494346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,887.26 |
| Max. Negotiated Rate |
$9,176.08 |
| Rate for Payer: Aetna Commercial |
$8,976.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,577.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,286.22
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,176.08
|
| Rate for Payer: Health EOS Commercial |
$8,876.86
|
| Rate for Payer: HFN Commercial |
$9,176.08
|
| Rate for Payer: Multiplan Commercial |
$7,979.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,984.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,176.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,887.26
|
| Rate for Payer: Quartz Commercial |
$5,984.40
|
| Rate for Payer: WEA Trust Commercial |
$5,485.70
|
| Rate for Payer: WPS Commercial |
$7,387.74
|
|
|
PLATE UNIVERSAL CROSSPLATE 5HL 626895
|
Facility
|
OP
|
$12,721.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5787771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,561.88 |
| Max. Negotiated Rate |
$50,884.00 |
| Rate for Payer: Aetna Commercial |
$11,448.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,940.06
|
| Rate for Payer: Aetna Managed Medicare |
$3,561.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,268.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,360.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,106.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,742.13
|
| Rate for Payer: Cash Price |
$3,816.30
|
| Rate for Payer: Cigna Commercial |
$11,703.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,118.67
|
| Rate for Payer: Health EOS Commercial |
$11,321.69
|
| Rate for Payer: HFN Commercial |
$11,703.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,540.75
|
| Rate for Payer: Multiplan Commercial |
$10,176.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,632.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,703.32
|
| Rate for Payer: Quartz Beloit One Network |
$6,233.29
|
| Rate for Payer: Quartz Commercial |
$8,268.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,632.60
|
| Rate for Payer: The Alliance Commercial |
$50,884.00
|
| Rate for Payer: WEA Trust Commercial |
$6,996.55
|
| Rate for Payer: WPS Commercial |
$9,422.44
|
|
|
PLATE UNIVERSAL CROSSPLATE 5HL 626895
|
Facility
|
IP
|
$12,721.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5787771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,233.29 |
| Max. Negotiated Rate |
$11,703.32 |
| Rate for Payer: Aetna Commercial |
$11,448.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,940.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,742.13
|
| Rate for Payer: Cash Price |
$3,816.30
|
| Rate for Payer: Cigna Commercial |
$11,703.32
|
| Rate for Payer: Health EOS Commercial |
$11,321.69
|
| Rate for Payer: HFN Commercial |
$11,703.32
|
| Rate for Payer: Multiplan Commercial |
$10,176.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,632.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,703.32
|
| Rate for Payer: Quartz Beloit One Network |
$6,233.29
|
| Rate for Payer: Quartz Commercial |
$7,632.60
|
| Rate for Payer: WEA Trust Commercial |
$6,996.55
|
| Rate for Payer: WPS Commercial |
$9,422.44
|
|
|
PLATE VA-LCP 3.5MM PROX TIBIA 4H 87MM LT 02.127.311S
|
Facility
|
IP
|
$14,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5264864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,893.81 |
| Max. Negotiated Rate |
$12,943.48 |
| Rate for Payer: Aetna Commercial |
$12,662.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,099.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,456.57
|
| Rate for Payer: Cash Price |
$4,220.70
|
| Rate for Payer: Cigna Commercial |
$12,943.48
|
| Rate for Payer: Health EOS Commercial |
$12,521.41
|
| Rate for Payer: HFN Commercial |
$12,943.48
|
| Rate for Payer: Multiplan Commercial |
$11,255.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,441.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,943.48
|
| Rate for Payer: Quartz Beloit One Network |
$6,893.81
|
| Rate for Payer: Quartz Commercial |
$8,441.40
|
| Rate for Payer: WEA Trust Commercial |
$7,737.95
|
| Rate for Payer: WPS Commercial |
$10,420.91
|
|
|
PLATE VA-LCP 3.5MM PROX TIBIA 4H 87MM LT 02.127.311S
|
Facility
|
OP
|
$14,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5264864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,939.32 |
| Max. Negotiated Rate |
$56,276.00 |
| Rate for Payer: Aetna Commercial |
$12,662.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,099.34
|
| Rate for Payer: Aetna Managed Medicare |
$3,939.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,144.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,034.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,753.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,456.57
|
| Rate for Payer: Cash Price |
$4,220.70
|
| Rate for Payer: Cigna Commercial |
$12,943.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,873.01
|
| Rate for Payer: Health EOS Commercial |
$12,521.41
|
| Rate for Payer: HFN Commercial |
$12,943.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,551.75
|
| Rate for Payer: Multiplan Commercial |
$11,255.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,441.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,943.48
|
| Rate for Payer: Quartz Beloit One Network |
$6,893.81
|
| Rate for Payer: Quartz Commercial |
$9,144.85
|
| Rate for Payer: Quartz Medicare Advantage |
$8,441.40
|
| Rate for Payer: The Alliance Commercial |
$56,276.00
|
| Rate for Payer: WEA Trust Commercial |
$7,737.95
|
| Rate for Payer: WPS Commercial |
$10,420.91
|
|
|
PLATE VALLUX COLINK P90 ST031
|
Facility
|
IP
|
$8,768.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6172084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,296.32 |
| Max. Negotiated Rate |
$8,066.56 |
| Rate for Payer: Aetna Commercial |
$7,891.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,540.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,647.04
|
| Rate for Payer: Cash Price |
$2,630.40
|
| Rate for Payer: Cigna Commercial |
$8,066.56
|
| Rate for Payer: Health EOS Commercial |
$7,803.52
|
| Rate for Payer: HFN Commercial |
$8,066.56
|
| Rate for Payer: Multiplan Commercial |
$7,014.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,066.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,296.32
|
| Rate for Payer: Quartz Commercial |
$5,260.80
|
| Rate for Payer: WEA Trust Commercial |
$4,822.40
|
| Rate for Payer: WPS Commercial |
$6,494.46
|
|
|
PLATE VALLUX COLINK P90 ST031
|
Facility
|
OP
|
$8,768.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6172084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,455.04 |
| Max. Negotiated Rate |
$35,072.00 |
| Rate for Payer: Aetna Commercial |
$7,891.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,540.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,455.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,699.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,384.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,208.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,647.04
|
| Rate for Payer: Cash Price |
$2,630.40
|
| Rate for Payer: Cigna Commercial |
$8,066.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,906.57
|
| Rate for Payer: Health EOS Commercial |
$7,803.52
|
| Rate for Payer: HFN Commercial |
$8,066.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,576.00
|
| Rate for Payer: Multiplan Commercial |
$7,014.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,066.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,296.32
|
| Rate for Payer: Quartz Commercial |
$5,699.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,260.80
|
| Rate for Payer: The Alliance Commercial |
$35,072.00
|
| Rate for Payer: WEA Trust Commercial |
$4,822.40
|
| Rate for Payer: WPS Commercial |
$6,494.46
|
|
|
PLATE VA OLECRANON 2.7MM/ 3.5MM LT 2HL 02.107.302S
|
Facility
|
OP
|
$7,938.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.64 |
| Max. Negotiated Rate |
$31,752.00 |
| Rate for Payer: Aetna Commercial |
$7,144.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.68
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,969.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,810.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,207.14
|
| Rate for Payer: Cash Price |
$2,381.40
|
| Rate for Payer: Cigna Commercial |
$7,302.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,442.10
|
| Rate for Payer: Health EOS Commercial |
$7,064.82
|
| Rate for Payer: HFN Commercial |
$7,302.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,953.50
|
| Rate for Payer: Multiplan Commercial |
$6,350.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.62
|
| Rate for Payer: Quartz Commercial |
$5,159.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.80
|
| Rate for Payer: The Alliance Commercial |
$31,752.00
|
| Rate for Payer: WEA Trust Commercial |
$4,365.90
|
| Rate for Payer: WPS Commercial |
$5,879.68
|
|
