|
PLATE 2.4 ST-SH DST.RD 442.479
|
Facility
|
OP
|
$4,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.38 |
| 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: Aetna Managed Medicare |
$1,218.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,828.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,175.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,088.65
|
| 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: Dean Health DHI/DHP/ASO |
$2,435.09
|
| Rate for Payer: Health EOS Commercial |
$3,872.71
|
| Rate for Payer: HFN Commercial |
$4,003.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,263.52
|
| Rate for Payer: Multiplan Commercial |
$3,481.09
|
| Rate for Payer: NAPHCARE Commercial |
$2,610.82
|
| 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 |
$2,828.38
|
| Rate for Payer: Quartz Medicare Advantage |
$2,610.82
|
| Rate for Payer: The Alliance Commercial |
$2,175.68
|
| Rate for Payer: WEA Trust Commercial |
$2,393.25
|
| Rate for Payer: WPS Commercial |
$3,222.94
|
|
|
PLATE 2.7/3.5 7HL RT FIBULA
|
Facility
|
IP
|
$6,012.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,063.72 |
| Max. Negotiated Rate |
$5,752.28 |
| Rate for Payer: Aetna Commercial |
$5,627.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,377.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,313.81
|
| Rate for Payer: Cash Price |
$1,803.60
|
| Rate for Payer: Cigna Commercial |
$5,752.28
|
| Rate for Payer: Health EOS Commercial |
$5,564.71
|
| Rate for Payer: HFN Commercial |
$5,752.28
|
| Rate for Payer: Multiplan Commercial |
$5,001.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,752.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,063.72
|
| Rate for Payer: Quartz Commercial |
$3,751.49
|
| Rate for Payer: WEA Trust Commercial |
$3,438.86
|
| Rate for Payer: WPS Commercial |
$4,631.04
|
|
|
PLATE 2.7/3.5 7HL RT FIBULA
|
Facility
|
OP
|
$6,012.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,750.69 |
| Max. Negotiated Rate |
$5,752.28 |
| Rate for Payer: Aetna Commercial |
$5,627.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,377.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,750.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,064.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,126.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,001.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,313.81
|
| Rate for Payer: Cash Price |
$1,803.60
|
| Rate for Payer: Cigna Commercial |
$5,752.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,498.98
|
| Rate for Payer: Health EOS Commercial |
$5,564.71
|
| Rate for Payer: HFN Commercial |
$5,752.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,689.36
|
| Rate for Payer: Multiplan Commercial |
$5,001.98
|
| Rate for Payer: NAPHCARE Commercial |
$3,751.49
|
| Rate for Payer: Preferred Network Access Commercial |
$5,752.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,063.72
|
| Rate for Payer: Quartz Commercial |
$4,064.11
|
| Rate for Payer: Quartz Medicare Advantage |
$3,751.49
|
| Rate for Payer: The Alliance Commercial |
$3,126.24
|
| Rate for Payer: WEA Trust Commercial |
$3,438.86
|
| Rate for Payer: WPS Commercial |
$4,631.04
|
|
|
PLATE 2.7/3.5 FIBULA 3HL RT 02.112.136
|
Facility
|
OP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3259477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
PLATE 2.7/3.5 FIBULA 3HL RT 02.112.136
|
Facility
|
IP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3259477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 10HL 02.112.047
|
Facility
|
IP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4315757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,496.37 |
| Max. Negotiated Rate |
$6,564.60 |
| Rate for Payer: Aetna Commercial |
$6,421.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,136.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,781.78
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,564.60
|
| Rate for Payer: Health EOS Commercial |
$6,350.54
|
| Rate for Payer: HFN Commercial |
$6,564.60
|
| Rate for Payer: Multiplan Commercial |
$5,708.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,564.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,496.37
|
| Rate for Payer: Quartz Commercial |
$4,281.26
|
| Rate for Payer: WEA Trust Commercial |
$3,924.49
|
| Rate for Payer: WPS Commercial |
$5,285.03
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 10HL 02.112.047
|
Facility
|
OP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4315757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,997.92 |
| Max. Negotiated Rate |
$6,564.60 |
| Rate for Payer: Aetna Commercial |
$6,421.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,136.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,997.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,638.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,567.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,425.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,781.78
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,564.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,993.10
|
| Rate for Payer: Health EOS Commercial |
$6,350.54
|
| Rate for Payer: HFN Commercial |
$6,564.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,351.58
|
| Rate for Payer: Multiplan Commercial |
$5,708.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,281.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,564.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,496.37
|
| Rate for Payer: Quartz Commercial |
$4,638.04
|
| Rate for Payer: Quartz Medicare Advantage |
$4,281.26
|
| Rate for Payer: The Alliance Commercial |
$3,567.72
|
| Rate for Payer: WEA Trust Commercial |
$3,924.49
|
| Rate for Payer: WPS Commercial |
$5,285.03
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 9HL RT 02.112.046
|
Facility
|
OP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4340248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,997.92 |
| Max. Negotiated Rate |
$6,564.60 |
| Rate for Payer: Aetna Commercial |
$6,421.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,136.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,997.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,638.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,567.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,425.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,781.78
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,564.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,993.10
|
| Rate for Payer: Health EOS Commercial |
$6,350.54
|
| Rate for Payer: HFN Commercial |
$6,564.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,351.58
|
| Rate for Payer: Multiplan Commercial |
$5,708.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,281.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,564.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,496.37
|
| Rate for Payer: Quartz Commercial |
$4,638.04
|
| Rate for Payer: Quartz Medicare Advantage |
$4,281.26
|
| Rate for Payer: The Alliance Commercial |
$3,567.72
|
| Rate for Payer: WEA Trust Commercial |
$3,924.49
|
| Rate for Payer: WPS Commercial |
$5,285.03
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 9HL RT 02.112.046
|
Facility
|
IP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4340248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,496.37 |
| Max. Negotiated Rate |
$6,564.60 |
| Rate for Payer: Aetna Commercial |
$6,421.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,136.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,781.78
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,564.60
|
| Rate for Payer: Health EOS Commercial |
$6,350.54
|
| Rate for Payer: HFN Commercial |
$6,564.60
|
| Rate for Payer: Multiplan Commercial |
$5,708.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,564.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,496.37
|
| Rate for Payer: Quartz Commercial |
$4,281.26
|
| Rate for Payer: WEA Trust Commercial |
$3,924.49
|
| Rate for Payer: WPS Commercial |
$5,285.03
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 4HL RT 02.118.202
|
Facility
|
OP
|
$7,771.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4268743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,262.92 |
| Max. Negotiated Rate |
$7,435.29 |
| Rate for Payer: Aetna Commercial |
$7,273.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.38
|
| Rate for Payer: Aetna Managed Medicare |
$2,262.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,253.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,040.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,879.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.38
|
| Rate for Payer: Cash Price |
$2,331.30
|
| Rate for Payer: Cigna Commercial |
$7,435.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,522.72
|
| Rate for Payer: Health EOS Commercial |
$7,192.84
|
| Rate for Payer: HFN Commercial |
$7,435.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,061.38
|
| Rate for Payer: Multiplan Commercial |
$6,465.47
|
| Rate for Payer: NAPHCARE Commercial |
$4,849.10
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.29
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.10
|
| Rate for Payer: Quartz Commercial |
$5,253.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,849.10
|
| Rate for Payer: The Alliance Commercial |
$4,040.92
|
| Rate for Payer: WEA Trust Commercial |
$4,445.01
|
| Rate for Payer: WPS Commercial |
$5,986.00
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 4HL RT 02.118.202
|
Facility
|
IP
|
$7,771.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4268743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,960.10 |
| Max. Negotiated Rate |
$7,435.29 |
| Rate for Payer: Aetna Commercial |
$7,273.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,950.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,283.38
|
| Rate for Payer: Cash Price |
$2,331.30
|
| Rate for Payer: Cigna Commercial |
$7,435.29
|
| Rate for Payer: Health EOS Commercial |
$7,192.84
|
| Rate for Payer: HFN Commercial |
$7,435.29
|
| Rate for Payer: Multiplan Commercial |
$6,465.47
|
| Rate for Payer: Preferred Network Access Commercial |
$7,435.29
|
| Rate for Payer: Quartz Beloit One Network |
$3,960.10
|
| Rate for Payer: Quartz Commercial |
$4,849.10
|
| Rate for Payer: WEA Trust Commercial |
$4,445.01
|
| Rate for Payer: WPS Commercial |
$5,986.00
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 6HL lT 02.118.205
|
Facility
|
IP
|
$7,789.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,969.27 |
| Max. Negotiated Rate |
$7,452.52 |
| Rate for Payer: Aetna Commercial |
$7,290.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,966.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,293.30
|
| Rate for Payer: Cash Price |
$2,336.70
|
| Rate for Payer: Cigna Commercial |
$7,452.52
|
| Rate for Payer: Health EOS Commercial |
$7,209.50
|
| Rate for Payer: HFN Commercial |
$7,452.52
|
| Rate for Payer: Multiplan Commercial |
$6,480.45
|
| Rate for Payer: Preferred Network Access Commercial |
$7,452.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,969.27
|
| Rate for Payer: Quartz Commercial |
$4,860.34
|
| Rate for Payer: WEA Trust Commercial |
$4,455.31
|
| Rate for Payer: WPS Commercial |
$5,999.87
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 6HL lT 02.118.205
|
Facility
|
OP
|
$7,789.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,268.16 |
| Max. Negotiated Rate |
$7,452.52 |
| Rate for Payer: Aetna Commercial |
$7,290.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,966.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,268.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,265.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,050.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,888.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,293.30
|
| Rate for Payer: Cash Price |
$2,336.70
|
| Rate for Payer: Cigna Commercial |
$7,452.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,533.20
|
| Rate for Payer: Health EOS Commercial |
$7,209.50
|
| Rate for Payer: HFN Commercial |
$7,452.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,075.42
|
| Rate for Payer: Multiplan Commercial |
$6,480.45
|
| Rate for Payer: NAPHCARE Commercial |
$4,860.34
|
| Rate for Payer: Preferred Network Access Commercial |
$7,452.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,969.27
|
| Rate for Payer: Quartz Commercial |
$5,265.36
|
| Rate for Payer: Quartz Medicare Advantage |
$4,860.34
|
| Rate for Payer: The Alliance Commercial |
$4,050.28
|
| Rate for Payer: WEA Trust Commercial |
$4,455.31
|
| Rate for Payer: WPS Commercial |
$5,999.87
|
|
|
PLATE 2.7 4HL LAT DIST FIBULA 02.112.139
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,156.46 |
| Max. Negotiated Rate |
$5,926.42 |
| Rate for Payer: Aetna Commercial |
$5,797.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,539.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,414.13
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,926.42
|
| Rate for Payer: Health EOS Commercial |
$5,733.17
|
| Rate for Payer: HFN Commercial |
$5,926.42
|
| Rate for Payer: Multiplan Commercial |
$5,153.41
|
| Rate for Payer: Preferred Network Access Commercial |
$5,926.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,156.46
|
| Rate for Payer: Quartz Commercial |
$3,865.06
|
| Rate for Payer: WEA Trust Commercial |
$3,542.97
|
| Rate for Payer: WPS Commercial |
$4,771.24
|
|
|
PLATE 2.7 4HL LAT DIST FIBULA 02.112.139
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,803.69 |
| Max. Negotiated Rate |
$5,926.42 |
| Rate for Payer: Aetna Commercial |
$5,797.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,539.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,803.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,187.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,220.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,092.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,414.13
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,926.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,604.91
|
| Rate for Payer: Health EOS Commercial |
$5,733.17
|
| Rate for Payer: HFN Commercial |
$5,926.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,831.32
|
| Rate for Payer: Multiplan Commercial |
$5,153.41
|
| Rate for Payer: NAPHCARE Commercial |
$3,865.06
|
| Rate for Payer: Preferred Network Access Commercial |
$5,926.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,156.46
|
| Rate for Payer: Quartz Commercial |
$4,187.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,865.06
|
| Rate for Payer: The Alliance Commercial |
$3,220.88
|
| Rate for Payer: WEA Trust Commercial |
$3,542.97
|
| Rate for Payer: WPS Commercial |
$4,771.24
|
|
|
PLATE 2.7 LATERAL DISTAL FIBULA 5 HOLE LEFT 02.118.405
|
Facility
|
IP
|
$7,594.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3323490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,869.90 |
| Max. Negotiated Rate |
$7,265.94 |
| Rate for Payer: Aetna Commercial |
$7,107.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,792.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,185.81
|
| Rate for Payer: Cash Price |
$2,278.20
|
| Rate for Payer: Cigna Commercial |
$7,265.94
|
| Rate for Payer: Health EOS Commercial |
$7,029.01
|
| Rate for Payer: HFN Commercial |
$7,265.94
|
| Rate for Payer: Multiplan Commercial |
$6,318.21
|
| Rate for Payer: Preferred Network Access Commercial |
$7,265.94
|
| Rate for Payer: Quartz Beloit One Network |
$3,869.90
|
| Rate for Payer: Quartz Commercial |
$4,738.66
|
| Rate for Payer: WEA Trust Commercial |
$4,343.77
|
| Rate for Payer: WPS Commercial |
$5,849.66
|
|
|
PLATE 2.7 LATERAL DISTAL FIBULA 5 HOLE LEFT 02.118.405
|
Facility
|
OP
|
$7,594.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3323490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,211.37 |
| Max. Negotiated Rate |
$7,265.94 |
| Rate for Payer: Aetna Commercial |
$7,107.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,792.07
|
| Rate for Payer: Aetna Managed Medicare |
$2,211.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,133.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,948.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,790.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,185.81
|
| Rate for Payer: Cash Price |
$2,278.20
|
| Rate for Payer: Cigna Commercial |
$7,265.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,419.71
|
| Rate for Payer: Health EOS Commercial |
$7,029.01
|
| Rate for Payer: HFN Commercial |
$7,265.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,923.32
|
| Rate for Payer: Multiplan Commercial |
$6,318.21
|
| Rate for Payer: NAPHCARE Commercial |
$4,738.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7,265.94
|
| Rate for Payer: Quartz Beloit One Network |
$3,869.90
|
| Rate for Payer: Quartz Commercial |
$5,133.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,738.66
|
| Rate for Payer: The Alliance Commercial |
$3,948.88
|
| Rate for Payer: WEA Trust Commercial |
$4,343.77
|
| Rate for Payer: WPS Commercial |
$5,849.66
|
|
|
PLATE 2.7 LCP 4HL 249.680
|
Facility
|
IP
|
$5,358.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,730.44 |
| Max. Negotiated Rate |
$5,126.53 |
| Rate for Payer: Aetna Commercial |
$5,015.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,792.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,953.33
|
| Rate for Payer: Cash Price |
$1,607.40
|
| Rate for Payer: Cigna Commercial |
$5,126.53
|
| Rate for Payer: Health EOS Commercial |
$4,959.36
|
| Rate for Payer: HFN Commercial |
$5,126.53
|
| Rate for Payer: Multiplan Commercial |
$4,457.86
|
| Rate for Payer: Preferred Network Access Commercial |
$5,126.53
|
| Rate for Payer: Quartz Beloit One Network |
$2,730.44
|
| Rate for Payer: Quartz Commercial |
$3,343.39
|
| Rate for Payer: WEA Trust Commercial |
$3,064.78
|
| Rate for Payer: WPS Commercial |
$4,127.27
|
|
|
PLATE 2.7 LCP 4HL 249.680
|
Facility
|
OP
|
$5,358.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,560.25 |
| Max. Negotiated Rate |
$5,126.53 |
| Rate for Payer: Aetna Commercial |
$5,015.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,792.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,560.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,622.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,786.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,674.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,953.33
|
| Rate for Payer: Cash Price |
$1,607.40
|
| Rate for Payer: Cigna Commercial |
$5,126.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,118.36
|
| Rate for Payer: Health EOS Commercial |
$4,959.36
|
| Rate for Payer: HFN Commercial |
$5,126.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,179.24
|
| Rate for Payer: Multiplan Commercial |
$4,457.86
|
| Rate for Payer: NAPHCARE Commercial |
$3,343.39
|
| Rate for Payer: Preferred Network Access Commercial |
$5,126.53
|
| Rate for Payer: Quartz Beloit One Network |
$2,730.44
|
| Rate for Payer: Quartz Commercial |
$3,622.01
|
| Rate for Payer: Quartz Medicare Advantage |
$3,343.39
|
| Rate for Payer: The Alliance Commercial |
$2,786.16
|
| Rate for Payer: WEA Trust Commercial |
$3,064.78
|
| Rate for Payer: WPS Commercial |
$4,127.27
|
|
|
PLATE 2.7 LCP 7HL 249.683
|
Facility
|
OP
|
$3,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,141.80 |
| Max. Negotiated Rate |
$3,751.61 |
| Rate for Payer: Aetna Commercial |
$3,670.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,506.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,141.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,650.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,038.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,957.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,161.26
|
| Rate for Payer: Cash Price |
$1,176.30
|
| Rate for Payer: Cigna Commercial |
$3,751.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,282.02
|
| Rate for Payer: Health EOS Commercial |
$3,629.28
|
| Rate for Payer: HFN Commercial |
$3,751.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,058.38
|
| Rate for Payer: Multiplan Commercial |
$3,262.27
|
| Rate for Payer: NAPHCARE Commercial |
$2,446.70
|
| Rate for Payer: Preferred Network Access Commercial |
$3,751.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,998.14
|
| Rate for Payer: Quartz Commercial |
$2,650.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,446.70
|
| Rate for Payer: The Alliance Commercial |
$2,038.92
|
| Rate for Payer: WEA Trust Commercial |
$2,242.81
|
| Rate for Payer: WPS Commercial |
$3,020.35
|
|
|
PLATE 2.7 LCP 7HL 249.683
|
Facility
|
IP
|
$3,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,998.14 |
| Max. Negotiated Rate |
$3,751.61 |
| Rate for Payer: Aetna Commercial |
$3,670.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,506.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,161.26
|
| Rate for Payer: Cash Price |
$1,176.30
|
| Rate for Payer: Cigna Commercial |
$3,751.61
|
| Rate for Payer: Health EOS Commercial |
$3,629.28
|
| Rate for Payer: HFN Commercial |
$3,751.61
|
| Rate for Payer: Multiplan Commercial |
$3,262.27
|
| Rate for Payer: Preferred Network Access Commercial |
$3,751.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,998.14
|
| Rate for Payer: Quartz Commercial |
$2,446.70
|
| Rate for Payer: WEA Trust Commercial |
$2,242.81
|
| Rate for Payer: WPS Commercial |
$3,020.35
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY 6 HOLE 02.111.900
|
Facility
|
OP
|
$5,201.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,514.53 |
| Max. Negotiated Rate |
$4,976.32 |
| Rate for Payer: Aetna Commercial |
$4,868.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,651.77
|
| Rate for Payer: Aetna Managed Medicare |
$1,514.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,515.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,704.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,596.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,866.79
|
| Rate for Payer: Cash Price |
$1,560.30
|
| Rate for Payer: Cigna Commercial |
$4,976.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,026.98
|
| Rate for Payer: Health EOS Commercial |
$4,814.05
|
| Rate for Payer: HFN Commercial |
$4,976.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,056.78
|
| Rate for Payer: Multiplan Commercial |
$4,327.23
|
| Rate for Payer: NAPHCARE Commercial |
$3,245.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,976.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,650.43
|
| Rate for Payer: Quartz Commercial |
$3,515.88
|
| Rate for Payer: Quartz Medicare Advantage |
$3,245.42
|
| Rate for Payer: The Alliance Commercial |
$2,704.52
|
| Rate for Payer: WEA Trust Commercial |
$2,974.97
|
| Rate for Payer: WPS Commercial |
$4,006.33
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY 6 HOLE 02.111.900
|
Facility
|
IP
|
$5,201.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,650.43 |
| Max. Negotiated Rate |
$4,976.32 |
| Rate for Payer: Aetna Commercial |
$4,868.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,651.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,866.79
|
| Rate for Payer: Cash Price |
$1,560.30
|
| Rate for Payer: Cigna Commercial |
$4,976.32
|
| Rate for Payer: Health EOS Commercial |
$4,814.05
|
| Rate for Payer: HFN Commercial |
$4,976.32
|
| Rate for Payer: Multiplan Commercial |
$4,327.23
|
| Rate for Payer: Preferred Network Access Commercial |
$4,976.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,650.43
|
| Rate for Payer: Quartz Commercial |
$3,245.42
|
| Rate for Payer: WEA Trust Commercial |
$2,974.97
|
| Rate for Payer: WPS Commercial |
$4,006.33
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY TI 6 HOLE 04.111.900
|
Facility
|
OP
|
$5,593.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,628.68 |
| Max. Negotiated Rate |
$5,351.38 |
| Rate for Payer: Aetna Commercial |
$5,235.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,002.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,628.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,780.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,908.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,792.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,082.86
|
| Rate for Payer: Cash Price |
$1,677.90
|
| Rate for Payer: Cigna Commercial |
$5,351.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,255.13
|
| Rate for Payer: Health EOS Commercial |
$5,176.88
|
| Rate for Payer: HFN Commercial |
$5,351.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,362.54
|
| Rate for Payer: Multiplan Commercial |
$4,653.38
|
| Rate for Payer: NAPHCARE Commercial |
$3,490.03
|
| Rate for Payer: Preferred Network Access Commercial |
$5,351.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,850.19
|
| Rate for Payer: Quartz Commercial |
$3,780.87
|
| Rate for Payer: Quartz Medicare Advantage |
$3,490.03
|
| Rate for Payer: The Alliance Commercial |
$2,908.36
|
| Rate for Payer: WEA Trust Commercial |
$3,199.20
|
| Rate for Payer: WPS Commercial |
$4,308.29
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY TI 6 HOLE 04.111.900
|
Facility
|
IP
|
$5,593.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,850.19 |
| Max. Negotiated Rate |
$5,351.38 |
| Rate for Payer: Aetna Commercial |
$5,235.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,002.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,082.86
|
| Rate for Payer: Cash Price |
$1,677.90
|
| Rate for Payer: Cigna Commercial |
$5,351.38
|
| Rate for Payer: Health EOS Commercial |
$5,176.88
|
| Rate for Payer: HFN Commercial |
$5,351.38
|
| Rate for Payer: Multiplan Commercial |
$4,653.38
|
| Rate for Payer: Preferred Network Access Commercial |
$5,351.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,850.19
|
| Rate for Payer: Quartz Commercial |
$3,490.03
|
| Rate for Payer: WEA Trust Commercial |
$3,199.20
|
| Rate for Payer: WPS Commercial |
$4,308.29
|
|
