|
PLATE 2.4 6HL/2H LT 04.111.621
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,815.92 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,815.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,215.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,242.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,113.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,629.35
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,864.08
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: NAPHCARE Commercial |
$3,891.26
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$4,215.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,891.26
|
| Rate for Payer: The Alliance Commercial |
$3,242.72
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 6HL/2H RT 04.111.620
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,815.92 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,815.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,215.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,242.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,113.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,629.35
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,864.08
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: NAPHCARE Commercial |
$3,891.26
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$4,215.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,891.26
|
| Rate for Payer: The Alliance Commercial |
$3,242.72
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 6HL/2H RT 04.111.620
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,177.87 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$3,891.26
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 6HL/3H LT 04.111.631
|
Facility
|
IP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.67 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,203.26
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 6HL/3H LT 04.111.631
|
Facility
|
OP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.52 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,502.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.35
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.08
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,553.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.26
|
| Rate for Payer: The Alliance Commercial |
$3,502.72
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 6HL/3H RT 04.111.630
|
Facility
|
OP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.52 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,502.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.35
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.08
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,553.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.26
|
| Rate for Payer: The Alliance Commercial |
$3,502.72
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 6HL/3H RT 04.111.630
|
Facility
|
IP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.67 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,203.26
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 6HL/4H LT 04.111.641
|
Facility
|
OP
|
$6,987.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,034.61 |
| Max. Negotiated Rate |
$6,685.16 |
| Rate for Payer: Aetna Commercial |
$6,539.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,249.17
|
| Rate for Payer: Aetna Managed Medicare |
$2,034.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,723.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,633.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,487.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,851.23
|
| Rate for Payer: Cash Price |
$2,096.10
|
| Rate for Payer: Cigna Commercial |
$6,685.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,066.43
|
| Rate for Payer: Health EOS Commercial |
$6,467.17
|
| Rate for Payer: HFN Commercial |
$6,685.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,449.86
|
| Rate for Payer: Multiplan Commercial |
$5,813.18
|
| Rate for Payer: NAPHCARE Commercial |
$4,359.89
|
| Rate for Payer: Preferred Network Access Commercial |
$6,685.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,560.58
|
| Rate for Payer: Quartz Commercial |
$4,723.21
|
| Rate for Payer: Quartz Medicare Advantage |
$4,359.89
|
| Rate for Payer: The Alliance Commercial |
$3,633.24
|
| Rate for Payer: WEA Trust Commercial |
$3,996.56
|
| Rate for Payer: WPS Commercial |
$5,382.09
|
|
|
PLATE 2.4 6HL/4H LT 04.111.641
|
Facility
|
IP
|
$6,987.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.58 |
| Max. Negotiated Rate |
$6,685.16 |
| Rate for Payer: Aetna Commercial |
$6,539.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,249.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,851.23
|
| Rate for Payer: Cash Price |
$2,096.10
|
| Rate for Payer: Cigna Commercial |
$6,685.16
|
| Rate for Payer: Health EOS Commercial |
$6,467.17
|
| Rate for Payer: HFN Commercial |
$6,685.16
|
| Rate for Payer: Multiplan Commercial |
$5,813.18
|
| Rate for Payer: Preferred Network Access Commercial |
$6,685.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,560.58
|
| Rate for Payer: Quartz Commercial |
$4,359.89
|
| Rate for Payer: WEA Trust Commercial |
$3,996.56
|
| Rate for Payer: WPS Commercial |
$5,382.09
|
|
|
PLATE 2.4 6HL/4H RT 04.111.640
|
Facility
|
IP
|
$6,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,429.10 |
| Max. Negotiated Rate |
$6,438.31 |
| Rate for Payer: Aetna Commercial |
$6,298.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,018.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,709.02
|
| Rate for Payer: Cash Price |
$2,018.70
|
| Rate for Payer: Cigna Commercial |
$6,438.31
|
| Rate for Payer: Health EOS Commercial |
$6,228.36
|
| Rate for Payer: HFN Commercial |
$6,438.31
|
| Rate for Payer: Multiplan Commercial |
$5,598.53
|
| Rate for Payer: Preferred Network Access Commercial |
$6,438.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,429.10
|
| Rate for Payer: Quartz Commercial |
$4,198.90
|
| Rate for Payer: WEA Trust Commercial |
$3,848.99
|
| Rate for Payer: WPS Commercial |
$5,183.35
|
|
|
PLATE 2.4 6HL/4H RT 04.111.640
|
Facility
|
OP
|
$6,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,959.48 |
| Max. Negotiated Rate |
$6,438.31 |
| Rate for Payer: Aetna Commercial |
$6,298.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,018.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,959.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,548.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,499.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,359.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,709.02
|
| Rate for Payer: Cash Price |
$2,018.70
|
| Rate for Payer: Cigna Commercial |
$6,438.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,916.28
|
| Rate for Payer: Health EOS Commercial |
$6,228.36
|
| Rate for Payer: HFN Commercial |
$6,438.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,248.62
|
| Rate for Payer: Multiplan Commercial |
$5,598.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,198.90
|
| Rate for Payer: Preferred Network Access Commercial |
$6,438.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,429.10
|
| Rate for Payer: Quartz Commercial |
$4,548.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,198.90
|
| Rate for Payer: The Alliance Commercial |
$3,499.08
|
| Rate for Payer: WEA Trust Commercial |
$3,848.99
|
| Rate for Payer: WPS Commercial |
$5,183.35
|
|
|
PLATE 2.4 6HL/5H LT 04.111.651
|
Facility
|
IP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,555.99 |
| Max. Negotiated Rate |
$6,676.55 |
| Rate for Payer: Aetna Commercial |
$6,531.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,241.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,846.27
|
| Rate for Payer: Cash Price |
$2,093.40
|
| Rate for Payer: Cigna Commercial |
$6,676.55
|
| Rate for Payer: Health EOS Commercial |
$6,458.84
|
| Rate for Payer: HFN Commercial |
$6,676.55
|
| Rate for Payer: Multiplan Commercial |
$5,805.70
|
| Rate for Payer: Preferred Network Access Commercial |
$6,676.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,555.99
|
| Rate for Payer: Quartz Commercial |
$4,354.27
|
| Rate for Payer: WEA Trust Commercial |
$3,991.42
|
| Rate for Payer: WPS Commercial |
$5,375.15
|
|
|
PLATE 2.4 6HL/5H LT 04.111.651
|
Facility
|
OP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,031.99 |
| Max. Negotiated Rate |
$6,676.55 |
| Rate for Payer: Aetna Commercial |
$6,531.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,241.12
|
| Rate for Payer: Aetna Managed Medicare |
$2,031.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,717.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,628.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,483.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,846.27
|
| Rate for Payer: Cash Price |
$2,093.40
|
| Rate for Payer: Cigna Commercial |
$6,676.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,061.20
|
| Rate for Payer: Health EOS Commercial |
$6,458.84
|
| Rate for Payer: HFN Commercial |
$6,676.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,442.84
|
| Rate for Payer: Multiplan Commercial |
$5,805.70
|
| Rate for Payer: NAPHCARE Commercial |
$4,354.27
|
| Rate for Payer: Preferred Network Access Commercial |
$6,676.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,555.99
|
| Rate for Payer: Quartz Commercial |
$4,717.13
|
| Rate for Payer: Quartz Medicare Advantage |
$4,354.27
|
| Rate for Payer: The Alliance Commercial |
$3,628.56
|
| Rate for Payer: WEA Trust Commercial |
$3,991.42
|
| Rate for Payer: WPS Commercial |
$5,375.15
|
|
|
PLATE 2.4 6HL/5H RT 04.111.650
|
Facility
|
IP
|
$7,247.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,693.07 |
| Max. Negotiated Rate |
$6,933.93 |
| Rate for Payer: Aetna Commercial |
$6,783.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,481.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,994.55
|
| Rate for Payer: Cash Price |
$2,174.10
|
| Rate for Payer: Cigna Commercial |
$6,933.93
|
| Rate for Payer: Health EOS Commercial |
$6,707.82
|
| Rate for Payer: HFN Commercial |
$6,933.93
|
| Rate for Payer: Multiplan Commercial |
$6,029.50
|
| Rate for Payer: Preferred Network Access Commercial |
$6,933.93
|
| Rate for Payer: Quartz Beloit One Network |
$3,693.07
|
| Rate for Payer: Quartz Commercial |
$4,522.13
|
| Rate for Payer: WEA Trust Commercial |
$4,145.28
|
| Rate for Payer: WPS Commercial |
$5,582.36
|
|
|
PLATE 2.4 6HL/5H RT 04.111.650
|
Facility
|
OP
|
$7,247.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,110.33 |
| Max. Negotiated Rate |
$6,933.93 |
| Rate for Payer: Aetna Commercial |
$6,783.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,481.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,110.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,898.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,768.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,617.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,994.55
|
| Rate for Payer: Cash Price |
$2,174.10
|
| Rate for Payer: Cigna Commercial |
$6,933.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,217.75
|
| Rate for Payer: Health EOS Commercial |
$6,707.82
|
| Rate for Payer: HFN Commercial |
$6,933.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,652.66
|
| Rate for Payer: Multiplan Commercial |
$6,029.50
|
| Rate for Payer: NAPHCARE Commercial |
$4,522.13
|
| Rate for Payer: Preferred Network Access Commercial |
$6,933.93
|
| Rate for Payer: Quartz Beloit One Network |
$3,693.07
|
| Rate for Payer: Quartz Commercial |
$4,898.97
|
| Rate for Payer: Quartz Medicare Advantage |
$4,522.13
|
| Rate for Payer: The Alliance Commercial |
$3,768.44
|
| Rate for Payer: WEA Trust Commercial |
$4,145.28
|
| Rate for Payer: WPS Commercial |
$5,582.36
|
|
|
PLATE 2.4 6HL LT DISTAL RADIUS
|
Facility
|
OP
|
$6,501.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,893.09 |
| Max. Negotiated Rate |
$6,220.16 |
| Rate for Payer: Aetna Commercial |
$6,084.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,814.49
|
| Rate for Payer: Aetna Managed Medicare |
$1,893.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,394.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,380.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,245.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,583.35
|
| Rate for Payer: Cash Price |
$1,950.30
|
| Rate for Payer: Cigna Commercial |
$6,220.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,783.58
|
| Rate for Payer: Health EOS Commercial |
$6,017.33
|
| Rate for Payer: HFN Commercial |
$6,220.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,070.78
|
| Rate for Payer: Multiplan Commercial |
$5,408.83
|
| Rate for Payer: NAPHCARE Commercial |
$4,056.62
|
| Rate for Payer: Preferred Network Access Commercial |
$6,220.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,312.91
|
| Rate for Payer: Quartz Commercial |
$4,394.68
|
| Rate for Payer: Quartz Medicare Advantage |
$4,056.62
|
| Rate for Payer: The Alliance Commercial |
$3,380.52
|
| Rate for Payer: WEA Trust Commercial |
$3,718.57
|
| Rate for Payer: WPS Commercial |
$5,007.72
|
|
|
PLATE 2.4 6HL LT DISTAL RADIUS
|
Facility
|
IP
|
$6,501.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,312.91 |
| Max. Negotiated Rate |
$6,220.16 |
| Rate for Payer: Aetna Commercial |
$6,084.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,814.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,583.35
|
| Rate for Payer: Cash Price |
$1,950.30
|
| Rate for Payer: Cigna Commercial |
$6,220.16
|
| Rate for Payer: Health EOS Commercial |
$6,017.33
|
| Rate for Payer: HFN Commercial |
$6,220.16
|
| Rate for Payer: Multiplan Commercial |
$5,408.83
|
| Rate for Payer: Preferred Network Access Commercial |
$6,220.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,312.91
|
| Rate for Payer: Quartz Commercial |
$4,056.62
|
| Rate for Payer: WEA Trust Commercial |
$3,718.57
|
| Rate for Payer: WPS Commercial |
$5,007.72
|
|
|
PLATE 2.4 7HL/2H LT 04.111.721
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,815.92 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,815.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,215.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,242.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,113.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,629.35
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,864.08
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: NAPHCARE Commercial |
$3,891.26
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$4,215.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,891.26
|
| Rate for Payer: The Alliance Commercial |
$3,242.72
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 7HL/2H LT 04.111.721
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,177.87 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$3,891.26
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 7HL/2H RT 04.111.720
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,177.87 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$3,891.26
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 7HL/2H RT 04.111.720
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,815.92 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,815.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,215.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,242.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,113.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,629.35
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,864.08
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: NAPHCARE Commercial |
$3,891.26
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$4,215.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,891.26
|
| Rate for Payer: The Alliance Commercial |
$3,242.72
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 7HL/3H LT 04.111.731
|
Facility
|
IP
|
$6,486.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,305.27 |
| Max. Negotiated Rate |
$6,205.80 |
| Rate for Payer: Aetna Commercial |
$6,070.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,801.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,575.08
|
| Rate for Payer: Cash Price |
$1,945.80
|
| Rate for Payer: Cigna Commercial |
$6,205.80
|
| Rate for Payer: Health EOS Commercial |
$6,003.44
|
| Rate for Payer: HFN Commercial |
$6,205.80
|
| Rate for Payer: Multiplan Commercial |
$5,396.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,205.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,305.27
|
| Rate for Payer: Quartz Commercial |
$4,047.26
|
| Rate for Payer: WEA Trust Commercial |
$3,709.99
|
| Rate for Payer: WPS Commercial |
$4,996.17
|
|
|
PLATE 2.4 7HL/3H LT 04.111.731
|
Facility
|
OP
|
$6,486.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,888.72 |
| Max. Negotiated Rate |
$6,205.80 |
| Rate for Payer: Aetna Commercial |
$6,070.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,801.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,888.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,384.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,372.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,237.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,575.08
|
| Rate for Payer: Cash Price |
$1,945.80
|
| Rate for Payer: Cigna Commercial |
$6,205.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,774.85
|
| Rate for Payer: Health EOS Commercial |
$6,003.44
|
| Rate for Payer: HFN Commercial |
$6,205.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,059.08
|
| Rate for Payer: Multiplan Commercial |
$5,396.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,047.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,205.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,305.27
|
| Rate for Payer: Quartz Commercial |
$4,384.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,047.26
|
| Rate for Payer: The Alliance Commercial |
$3,372.72
|
| Rate for Payer: WEA Trust Commercial |
$3,709.99
|
| Rate for Payer: WPS Commercial |
$4,996.17
|
|
|
PLATE 2.4 7HL/3H RT 04.111.730
|
Facility
|
OP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.52 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,502.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.35
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.08
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,553.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.26
|
| Rate for Payer: The Alliance Commercial |
$3,502.72
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 7HL/3H RT 04.111.730
|
Facility
|
IP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.67 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,203.26
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
