|
PLATE 2.4 7HL/4H LT 04.111.741
|
Facility
|
OP
|
$6,987.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966691
|
|
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 7HL/4H LT 04.111.741
|
Facility
|
IP
|
$6,987.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966691
|
|
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 7HL/4H RT 04.111.740
|
Facility
|
OP
|
$6,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966692
|
|
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 7HL/4H RT 04.111.740
|
Facility
|
IP
|
$6,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966692
|
|
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 7HL/5H LT 04.111.751
|
Facility
|
OP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966693
|
|
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 7HL/5H LT 04.111.751
|
Facility
|
IP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966693
|
|
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 7HL/5H RT 04.111.750
|
Facility
|
OP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966694
|
|
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 7HL/5H RT 04.111.750
|
Facility
|
IP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966694
|
|
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 DISTAL RADIUS 6HL HEAD 3HL SHAFT LT 02.111.631S
|
Facility
|
IP
|
$7,354.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3603522
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,747.60 |
| Max. Negotiated Rate |
$7,036.31 |
| Rate for Payer: Aetna Commercial |
$6,883.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,577.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,053.52
|
| Rate for Payer: Cash Price |
$2,206.20
|
| Rate for Payer: Cigna Commercial |
$7,036.31
|
| Rate for Payer: Health EOS Commercial |
$6,806.86
|
| Rate for Payer: HFN Commercial |
$7,036.31
|
| Rate for Payer: Multiplan Commercial |
$6,118.53
|
| Rate for Payer: Preferred Network Access Commercial |
$7,036.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,747.60
|
| Rate for Payer: Quartz Commercial |
$4,588.90
|
| Rate for Payer: WEA Trust Commercial |
$4,206.49
|
| Rate for Payer: WPS Commercial |
$5,664.79
|
|
|
PLATE 2.4 DISTAL RADIUS 6HL HEAD 3HL SHAFT LT 02.111.631S
|
Facility
|
OP
|
$7,354.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3603522
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,141.48 |
| Max. Negotiated Rate |
$7,036.31 |
| Rate for Payer: Aetna Commercial |
$6,883.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,577.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,141.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,971.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,824.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,671.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,053.52
|
| Rate for Payer: Cash Price |
$2,206.20
|
| Rate for Payer: Cigna Commercial |
$7,036.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,280.03
|
| Rate for Payer: Health EOS Commercial |
$6,806.86
|
| Rate for Payer: HFN Commercial |
$7,036.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,736.12
|
| Rate for Payer: Multiplan Commercial |
$6,118.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,588.90
|
| Rate for Payer: Preferred Network Access Commercial |
$7,036.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,747.60
|
| Rate for Payer: Quartz Commercial |
$4,971.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,588.90
|
| Rate for Payer: The Alliance Commercial |
$3,824.08
|
| Rate for Payer: WEA Trust Commercial |
$4,206.49
|
| Rate for Payer: WPS Commercial |
$5,664.79
|
|
|
PLATE 2.4 DISTAL RADIUS 6 HOLE 2 COLUMN RIGHT 02.111.650S
|
Facility
|
IP
|
$5,258.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3529515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,679.48 |
| Max. Negotiated Rate |
$5,030.85 |
| Rate for Payer: Aetna Commercial |
$4,921.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,702.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,898.21
|
| Rate for Payer: Cash Price |
$1,577.40
|
| Rate for Payer: Cigna Commercial |
$5,030.85
|
| Rate for Payer: Health EOS Commercial |
$4,866.80
|
| Rate for Payer: HFN Commercial |
$5,030.85
|
| Rate for Payer: Multiplan Commercial |
$4,374.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,030.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,679.48
|
| Rate for Payer: Quartz Commercial |
$3,280.99
|
| Rate for Payer: WEA Trust Commercial |
$3,007.58
|
| Rate for Payer: WPS Commercial |
$4,050.24
|
|
|
PLATE 2.4 DISTAL RADIUS 6 HOLE 2 COLUMN RIGHT 02.111.650S
|
Facility
|
OP
|
$5,258.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3529515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,531.13 |
| Max. Negotiated Rate |
$5,030.85 |
| Rate for Payer: Aetna Commercial |
$4,921.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,702.76
|
| Rate for Payer: Aetna Managed Medicare |
$1,531.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,554.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,734.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,624.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,898.21
|
| Rate for Payer: Cash Price |
$1,577.40
|
| Rate for Payer: Cigna Commercial |
$5,030.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,060.16
|
| Rate for Payer: Health EOS Commercial |
$4,866.80
|
| Rate for Payer: HFN Commercial |
$5,030.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,101.24
|
| Rate for Payer: Multiplan Commercial |
$4,374.66
|
| Rate for Payer: NAPHCARE Commercial |
$3,280.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5,030.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,679.48
|
| Rate for Payer: Quartz Commercial |
$3,554.41
|
| Rate for Payer: Quartz Medicare Advantage |
$3,280.99
|
| Rate for Payer: The Alliance Commercial |
$2,734.16
|
| Rate for Payer: WEA Trust Commercial |
$3,007.58
|
| Rate for Payer: WPS Commercial |
$4,050.24
|
|
|
PLATE 2.4 DIST RAD 6HL/4HL LT
|
Facility
|
IP
|
$7,036.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.55 |
| Max. Negotiated Rate |
$6,732.04 |
| Rate for Payer: Aetna Commercial |
$6,585.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.24
|
| Rate for Payer: Cash Price |
$2,110.80
|
| Rate for Payer: Cigna Commercial |
$6,732.04
|
| Rate for Payer: Health EOS Commercial |
$6,512.52
|
| Rate for Payer: HFN Commercial |
$6,732.04
|
| Rate for Payer: Multiplan Commercial |
$5,853.95
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.55
|
| Rate for Payer: Quartz Commercial |
$4,390.46
|
| Rate for Payer: WEA Trust Commercial |
$4,024.59
|
| Rate for Payer: WPS Commercial |
$5,419.83
|
|
|
PLATE 2.4 DIST RAD 6HL/4HL LT
|
Facility
|
OP
|
$7,036.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,048.88 |
| Max. Negotiated Rate |
$6,732.04 |
| Rate for Payer: Aetna Commercial |
$6,585.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,048.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,658.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.24
|
| Rate for Payer: Cash Price |
$2,110.80
|
| Rate for Payer: Cigna Commercial |
$6,732.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,094.95
|
| Rate for Payer: Health EOS Commercial |
$6,512.52
|
| Rate for Payer: HFN Commercial |
$6,732.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.08
|
| Rate for Payer: Multiplan Commercial |
$5,853.95
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.46
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.55
|
| Rate for Payer: Quartz Commercial |
$4,756.34
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.46
|
| Rate for Payer: The Alliance Commercial |
$3,658.72
|
| Rate for Payer: WEA Trust Commercial |
$4,024.59
|
| Rate for Payer: WPS Commercial |
$5,419.83
|
|
|
PLATE 2.4 DIST RAD L- 2HL/4HL
|
Facility
|
OP
|
$6,015.00
|
|
| Hospital Charge Code |
2966326
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,751.57 |
| Max. Negotiated Rate |
$5,755.15 |
| Rate for Payer: Aetna Commercial |
$5,630.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,379.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,751.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,066.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,127.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,002.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,315.47
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cigna Commercial |
$5,755.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,500.73
|
| Rate for Payer: Health EOS Commercial |
$5,567.48
|
| Rate for Payer: HFN Commercial |
$5,755.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,691.70
|
| Rate for Payer: Multiplan Commercial |
$5,004.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,753.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,755.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,065.24
|
| Rate for Payer: Quartz Commercial |
$4,066.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,753.36
|
| Rate for Payer: The Alliance Commercial |
$3,127.80
|
| Rate for Payer: WEA Trust Commercial |
$3,440.58
|
| Rate for Payer: WPS Commercial |
$4,633.35
|
|
|
PLATE 2.4 DIST RAD L- 2HL/4HL
|
Facility
|
IP
|
$6,015.00
|
|
| Hospital Charge Code |
2966326
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,065.24 |
| Max. Negotiated Rate |
$5,755.15 |
| Rate for Payer: Aetna Commercial |
$5,630.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,379.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,315.47
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cigna Commercial |
$5,755.15
|
| Rate for Payer: Health EOS Commercial |
$5,567.48
|
| Rate for Payer: HFN Commercial |
$5,755.15
|
| Rate for Payer: Multiplan Commercial |
$5,004.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,755.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,065.24
|
| Rate for Payer: Quartz Commercial |
$3,753.36
|
| Rate for Payer: WEA Trust Commercial |
$3,440.58
|
| Rate for Payer: WPS Commercial |
$4,633.35
|
|
|
PLATE 2.4 DIST RAD VOLAR LT SHORT 442.491
|
Facility
|
OP
|
$5,346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.76 |
| Max. Negotiated Rate |
$5,115.05 |
| Rate for Payer: Aetna Commercial |
$5,003.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,781.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,556.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,613.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,779.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,668.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,946.72
|
| Rate for Payer: Cash Price |
$1,603.80
|
| Rate for Payer: Cigna Commercial |
$5,115.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,111.37
|
| Rate for Payer: Health EOS Commercial |
$4,948.26
|
| Rate for Payer: HFN Commercial |
$5,115.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,169.88
|
| Rate for Payer: Multiplan Commercial |
$4,447.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,335.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,115.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,724.32
|
| Rate for Payer: Quartz Commercial |
$3,613.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,335.90
|
| Rate for Payer: The Alliance Commercial |
$2,779.92
|
| Rate for Payer: WEA Trust Commercial |
$3,057.91
|
| Rate for Payer: WPS Commercial |
$4,118.02
|
|
|
PLATE 2.4 DIST RAD VOLAR LT SHORT 442.491
|
Facility
|
IP
|
$5,346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,724.32 |
| Max. Negotiated Rate |
$5,115.05 |
| Rate for Payer: Aetna Commercial |
$5,003.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,781.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,946.72
|
| Rate for Payer: Cash Price |
$1,603.80
|
| Rate for Payer: Cigna Commercial |
$5,115.05
|
| Rate for Payer: Health EOS Commercial |
$4,948.26
|
| Rate for Payer: HFN Commercial |
$5,115.05
|
| Rate for Payer: Multiplan Commercial |
$4,447.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,115.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,724.32
|
| Rate for Payer: Quartz Commercial |
$3,335.90
|
| Rate for Payer: WEA Trust Commercial |
$3,057.91
|
| Rate for Payer: WPS Commercial |
$4,118.02
|
|
|
PLATE 2.4 DIST RAD VOLAR RT LONG 442.494
|
Facility
|
OP
|
$5,663.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632614
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,649.07 |
| Max. Negotiated Rate |
$5,418.36 |
| Rate for Payer: Aetna Commercial |
$5,300.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,064.99
|
| Rate for Payer: Aetna Managed Medicare |
$1,649.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,828.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,944.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,826.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,121.45
|
| Rate for Payer: Cash Price |
$1,698.90
|
| Rate for Payer: Cigna Commercial |
$5,418.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,295.87
|
| Rate for Payer: Health EOS Commercial |
$5,241.67
|
| Rate for Payer: HFN Commercial |
$5,418.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,417.14
|
| Rate for Payer: Multiplan Commercial |
$4,711.62
|
| Rate for Payer: NAPHCARE Commercial |
$3,533.71
|
| Rate for Payer: Preferred Network Access Commercial |
$5,418.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,885.86
|
| Rate for Payer: Quartz Commercial |
$3,828.19
|
| Rate for Payer: Quartz Medicare Advantage |
$3,533.71
|
| Rate for Payer: The Alliance Commercial |
$2,944.76
|
| Rate for Payer: WEA Trust Commercial |
$3,239.24
|
| Rate for Payer: WPS Commercial |
$4,362.21
|
|
|
PLATE 2.4 DIST RAD VOLAR RT LONG 442.494
|
Facility
|
IP
|
$5,663.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632614
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,885.86 |
| Max. Negotiated Rate |
$5,418.36 |
| Rate for Payer: Aetna Commercial |
$5,300.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,064.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,121.45
|
| Rate for Payer: Cash Price |
$1,698.90
|
| Rate for Payer: Cigna Commercial |
$5,418.36
|
| Rate for Payer: Health EOS Commercial |
$5,241.67
|
| Rate for Payer: HFN Commercial |
$5,418.36
|
| Rate for Payer: Multiplan Commercial |
$4,711.62
|
| Rate for Payer: Preferred Network Access Commercial |
$5,418.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,885.86
|
| Rate for Payer: Quartz Commercial |
$3,533.71
|
| Rate for Payer: WEA Trust Commercial |
$3,239.24
|
| Rate for Payer: WPS Commercial |
$4,362.21
|
|
|
PLATE 2.4 DIST RAD VOLAR RT SHORT 442.493
|
Facility
|
OP
|
$5,346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.76 |
| Max. Negotiated Rate |
$5,115.05 |
| Rate for Payer: Aetna Commercial |
$5,003.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,781.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,556.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,613.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,779.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,668.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,946.72
|
| Rate for Payer: Cash Price |
$1,603.80
|
| Rate for Payer: Cigna Commercial |
$5,115.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,111.37
|
| Rate for Payer: Health EOS Commercial |
$4,948.26
|
| Rate for Payer: HFN Commercial |
$5,115.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,169.88
|
| Rate for Payer: Multiplan Commercial |
$4,447.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,335.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,115.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,724.32
|
| Rate for Payer: Quartz Commercial |
$3,613.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,335.90
|
| Rate for Payer: The Alliance Commercial |
$2,779.92
|
| Rate for Payer: WEA Trust Commercial |
$3,057.91
|
| Rate for Payer: WPS Commercial |
$4,118.02
|
|
|
PLATE 2.4 DIST RAD VOLAR RT SHORT 442.493
|
Facility
|
IP
|
$5,346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,724.32 |
| Max. Negotiated Rate |
$5,115.05 |
| Rate for Payer: Aetna Commercial |
$5,003.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,781.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,946.72
|
| Rate for Payer: Cash Price |
$1,603.80
|
| Rate for Payer: Cigna Commercial |
$5,115.05
|
| Rate for Payer: Health EOS Commercial |
$4,948.26
|
| Rate for Payer: HFN Commercial |
$5,115.05
|
| Rate for Payer: Multiplan Commercial |
$4,447.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,115.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,724.32
|
| Rate for Payer: Quartz Commercial |
$3,335.90
|
| Rate for Payer: WEA Trust Commercial |
$3,057.91
|
| Rate for Payer: WPS Commercial |
$4,118.02
|
|
|
PLATE 2.4 ST-LG DST/RD 442.490
|
Facility
|
IP
|
$4,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,246.32 |
| Max. Negotiated Rate |
$4,217.57 |
| Rate for Payer: Aetna Commercial |
$4,125.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,942.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,429.69
|
| Rate for Payer: Cash Price |
$1,322.40
|
| Rate for Payer: Cigna Commercial |
$4,217.57
|
| Rate for Payer: Health EOS Commercial |
$4,080.04
|
| Rate for Payer: HFN Commercial |
$4,217.57
|
| Rate for Payer: Multiplan Commercial |
$3,667.46
|
| Rate for Payer: Preferred Network Access Commercial |
$4,217.57
|
| Rate for Payer: Quartz Beloit One Network |
$2,246.32
|
| Rate for Payer: Quartz Commercial |
$2,750.59
|
| Rate for Payer: WEA Trust Commercial |
$2,521.38
|
| Rate for Payer: WPS Commercial |
$3,395.48
|
|
|
PLATE 2.4 ST-LG DST/RD 442.490
|
Facility
|
OP
|
$4,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,283.61 |
| Max. Negotiated Rate |
$4,217.57 |
| Rate for Payer: Aetna Commercial |
$4,125.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,942.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,283.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,979.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,292.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,200.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,429.69
|
| Rate for Payer: Cash Price |
$1,322.40
|
| Rate for Payer: Cigna Commercial |
$4,217.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,565.46
|
| Rate for Payer: Health EOS Commercial |
$4,080.04
|
| Rate for Payer: HFN Commercial |
$4,217.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,438.24
|
| Rate for Payer: Multiplan Commercial |
$3,667.46
|
| Rate for Payer: NAPHCARE Commercial |
$2,750.59
|
| Rate for Payer: Preferred Network Access Commercial |
$4,217.57
|
| Rate for Payer: Quartz Beloit One Network |
$2,246.32
|
| Rate for Payer: Quartz Commercial |
$2,979.81
|
| Rate for Payer: Quartz Medicare Advantage |
$2,750.59
|
| Rate for Payer: The Alliance Commercial |
$2,292.16
|
| Rate for Payer: WEA Trust Commercial |
$2,521.38
|
| Rate for Payer: WPS Commercial |
$3,395.48
|
|
|
PLATE 2.4 ST-SH DST.RD 442.479
|
Facility
|
IP
|
$4,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,132.17 |
| Max. Negotiated Rate |
$4,003.25 |
| Rate for Payer: Aetna Commercial |
$3,916.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,742.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,306.22
|
| Rate for Payer: Cash Price |
$1,255.20
|
| Rate for Payer: Cigna Commercial |
$4,003.25
|
| Rate for Payer: Health EOS Commercial |
$3,872.71
|
| Rate for Payer: HFN Commercial |
$4,003.25
|
| Rate for Payer: Multiplan Commercial |
$3,481.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,003.25
|
| Rate for Payer: Quartz Beloit One Network |
$2,132.17
|
| Rate for Payer: Quartz Commercial |
$2,610.82
|
| Rate for Payer: WEA Trust Commercial |
$2,393.25
|
| Rate for Payer: WPS Commercial |
$3,222.94
|
|
