|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 3HL LT 02.118.401S
|
Facility
|
IP
|
$6,148.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5179147
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,133.02 |
| Max. Negotiated Rate |
$5,882.41 |
| Rate for Payer: Aetna Commercial |
$5,754.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,498.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,388.78
|
| Rate for Payer: Cash Price |
$1,844.40
|
| Rate for Payer: Cigna Commercial |
$5,882.41
|
| Rate for Payer: Health EOS Commercial |
$5,690.59
|
| Rate for Payer: HFN Commercial |
$5,882.41
|
| Rate for Payer: Multiplan Commercial |
$5,115.14
|
| Rate for Payer: Preferred Network Access Commercial |
$5,882.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,133.02
|
| Rate for Payer: Quartz Commercial |
$3,836.35
|
| Rate for Payer: WEA Trust Commercial |
$3,516.66
|
| Rate for Payer: WPS Commercial |
$4,735.80
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 3HL LT 02.118.401S
|
Facility
|
OP
|
$6,148.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5179147
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,790.30 |
| Max. Negotiated Rate |
$5,882.41 |
| Rate for Payer: Aetna Commercial |
$5,754.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,498.77
|
| Rate for Payer: Aetna Managed Medicare |
$1,790.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,156.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,196.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,069.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,388.78
|
| Rate for Payer: Cash Price |
$1,844.40
|
| Rate for Payer: Cigna Commercial |
$5,882.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,578.14
|
| Rate for Payer: Health EOS Commercial |
$5,690.59
|
| Rate for Payer: HFN Commercial |
$5,882.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,795.44
|
| Rate for Payer: Multiplan Commercial |
$5,115.14
|
| Rate for Payer: NAPHCARE Commercial |
$3,836.35
|
| Rate for Payer: Preferred Network Access Commercial |
$5,882.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,133.02
|
| Rate for Payer: Quartz Commercial |
$4,156.05
|
| Rate for Payer: Quartz Medicare Advantage |
$3,836.35
|
| Rate for Payer: The Alliance Commercial |
$3,196.96
|
| Rate for Payer: WEA Trust Commercial |
$3,516.66
|
| Rate for Payer: WPS Commercial |
$4,735.80
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 4HL RT 02.118.402
|
Facility
|
IP
|
$7,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.96 |
| Max. Negotiated Rate |
$6,922.45 |
| Rate for Payer: Aetna Commercial |
$6,771.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,470.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,987.93
|
| Rate for Payer: Cash Price |
$2,170.50
|
| Rate for Payer: Cigna Commercial |
$6,922.45
|
| Rate for Payer: Health EOS Commercial |
$6,696.72
|
| Rate for Payer: HFN Commercial |
$6,922.45
|
| Rate for Payer: Multiplan Commercial |
$6,019.52
|
| Rate for Payer: Preferred Network Access Commercial |
$6,922.45
|
| Rate for Payer: Quartz Beloit One Network |
$3,686.96
|
| Rate for Payer: Quartz Commercial |
$4,514.64
|
| Rate for Payer: WEA Trust Commercial |
$4,138.42
|
| Rate for Payer: WPS Commercial |
$5,573.12
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 4HL RT 02.118.402
|
Facility
|
OP
|
$7,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,106.83 |
| Max. Negotiated Rate |
$6,922.45 |
| Rate for Payer: Aetna Commercial |
$6,771.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,470.98
|
| Rate for Payer: Aetna Managed Medicare |
$2,106.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,890.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,762.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,611.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,987.93
|
| Rate for Payer: Cash Price |
$2,170.50
|
| Rate for Payer: Cigna Commercial |
$6,922.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,210.77
|
| Rate for Payer: Health EOS Commercial |
$6,696.72
|
| Rate for Payer: HFN Commercial |
$6,922.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,643.30
|
| Rate for Payer: Multiplan Commercial |
$6,019.52
|
| Rate for Payer: NAPHCARE Commercial |
$4,514.64
|
| Rate for Payer: Preferred Network Access Commercial |
$6,922.45
|
| Rate for Payer: Quartz Beloit One Network |
$3,686.96
|
| Rate for Payer: Quartz Commercial |
$4,890.86
|
| Rate for Payer: Quartz Medicare Advantage |
$4,514.64
|
| Rate for Payer: The Alliance Commercial |
$3,762.20
|
| Rate for Payer: WEA Trust Commercial |
$4,138.42
|
| Rate for Payer: WPS Commercial |
$5,573.12
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 6 HL LT 02.118.407
|
Facility
|
OP
|
$7,979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937359
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.48 |
| Max. Negotiated Rate |
$7,634.31 |
| Rate for Payer: Aetna Commercial |
$7,468.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,136.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,323.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,393.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,149.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,983.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,398.02
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,634.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,643.78
|
| Rate for Payer: Health EOS Commercial |
$7,385.36
|
| Rate for Payer: HFN Commercial |
$7,634.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,223.62
|
| Rate for Payer: Multiplan Commercial |
$6,638.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,978.90
|
| Rate for Payer: Preferred Network Access Commercial |
$7,634.31
|
| Rate for Payer: Quartz Beloit One Network |
$4,066.10
|
| Rate for Payer: Quartz Commercial |
$5,393.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,978.90
|
| Rate for Payer: The Alliance Commercial |
$4,149.08
|
| Rate for Payer: WEA Trust Commercial |
$4,563.99
|
| Rate for Payer: WPS Commercial |
$6,146.22
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 6 HL LT 02.118.407
|
Facility
|
IP
|
$7,979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937359
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,066.10 |
| Max. Negotiated Rate |
$7,634.31 |
| Rate for Payer: Aetna Commercial |
$7,468.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,136.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,398.02
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,634.31
|
| Rate for Payer: Health EOS Commercial |
$7,385.36
|
| Rate for Payer: HFN Commercial |
$7,634.31
|
| Rate for Payer: Multiplan Commercial |
$6,638.53
|
| Rate for Payer: Preferred Network Access Commercial |
$7,634.31
|
| Rate for Payer: Quartz Beloit One Network |
$4,066.10
|
| Rate for Payer: Quartz Commercial |
$4,978.90
|
| Rate for Payer: WEA Trust Commercial |
$4,563.99
|
| Rate for Payer: WPS Commercial |
$6,146.22
|
|
|
PLATE 2-COLUMN RT VOL DIST RAD 02.111.640
|
Facility
|
IP
|
$6,518.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,321.57 |
| Max. Negotiated Rate |
$6,236.42 |
| Rate for Payer: Aetna Commercial |
$6,100.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,829.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,592.72
|
| Rate for Payer: Cash Price |
$1,955.40
|
| Rate for Payer: Cigna Commercial |
$6,236.42
|
| Rate for Payer: Health EOS Commercial |
$6,033.06
|
| Rate for Payer: HFN Commercial |
$6,236.42
|
| Rate for Payer: Multiplan Commercial |
$5,422.98
|
| Rate for Payer: Preferred Network Access Commercial |
$6,236.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,321.57
|
| Rate for Payer: Quartz Commercial |
$4,067.23
|
| Rate for Payer: WEA Trust Commercial |
$3,728.30
|
| Rate for Payer: WPS Commercial |
$5,020.82
|
|
|
PLATE 2-COLUMN RT VOL DIST RAD 02.111.640
|
Facility
|
OP
|
$6,518.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,898.04 |
| Max. Negotiated Rate |
$6,236.42 |
| Rate for Payer: Aetna Commercial |
$6,100.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,829.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,898.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,406.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,389.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,253.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,592.72
|
| Rate for Payer: Cash Price |
$1,955.40
|
| Rate for Payer: Cigna Commercial |
$6,236.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,793.48
|
| Rate for Payer: Health EOS Commercial |
$6,033.06
|
| Rate for Payer: HFN Commercial |
$6,236.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,084.04
|
| Rate for Payer: Multiplan Commercial |
$5,422.98
|
| Rate for Payer: NAPHCARE Commercial |
$4,067.23
|
| Rate for Payer: Preferred Network Access Commercial |
$6,236.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,321.57
|
| Rate for Payer: Quartz Commercial |
$4,406.17
|
| Rate for Payer: Quartz Medicare Advantage |
$4,067.23
|
| Rate for Payer: The Alliance Commercial |
$3,389.36
|
| Rate for Payer: WEA Trust Commercial |
$3,728.30
|
| Rate for Payer: WPS Commercial |
$5,020.82
|
|
|
PLATE 2HH/3HS L -90 442.500
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,244.88 |
| Max. Negotiated Rate |
$4,090.32 |
| Rate for Payer: Aetna Commercial |
$4,001.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,823.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,244.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,889.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,134.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,356.38
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$4,090.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,488.05
|
| Rate for Payer: Health EOS Commercial |
$3,956.94
|
| Rate for Payer: HFN Commercial |
$4,090.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,334.50
|
| Rate for Payer: Multiplan Commercial |
$3,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,667.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,090.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,178.54
|
| Rate for Payer: Quartz Commercial |
$2,889.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,667.60
|
| Rate for Payer: The Alliance Commercial |
$2,223.00
|
| Rate for Payer: WEA Trust Commercial |
$2,445.30
|
| Rate for Payer: WPS Commercial |
$3,293.03
|
|
|
PLATE 2HH/3HS L -90 442.500
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.54 |
| Max. Negotiated Rate |
$4,090.32 |
| Rate for Payer: Aetna Commercial |
$4,001.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,823.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,356.38
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$4,090.32
|
| Rate for Payer: Health EOS Commercial |
$3,956.94
|
| Rate for Payer: HFN Commercial |
$4,090.32
|
| Rate for Payer: Multiplan Commercial |
$3,556.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,090.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,178.54
|
| Rate for Payer: Quartz Commercial |
$2,667.60
|
| Rate for Payer: WEA Trust Commercial |
$2,445.30
|
| Rate for Payer: WPS Commercial |
$3,293.03
|
|
|
PLATE 2HH/3HS L +90 442.502
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,244.88 |
| Max. Negotiated Rate |
$4,090.32 |
| Rate for Payer: Aetna Commercial |
$4,001.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,823.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,244.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,889.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,134.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,356.38
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$4,090.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,488.05
|
| Rate for Payer: Health EOS Commercial |
$3,956.94
|
| Rate for Payer: HFN Commercial |
$4,090.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,334.50
|
| Rate for Payer: Multiplan Commercial |
$3,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,667.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,090.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,178.54
|
| Rate for Payer: Quartz Commercial |
$2,889.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,667.60
|
| Rate for Payer: The Alliance Commercial |
$2,223.00
|
| Rate for Payer: WEA Trust Commercial |
$2,445.30
|
| Rate for Payer: WPS Commercial |
$3,293.03
|
|
|
PLATE 2HH/3HS L +90 442.502
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.54 |
| Max. Negotiated Rate |
$4,090.32 |
| Rate for Payer: Aetna Commercial |
$4,001.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,823.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,356.38
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$4,090.32
|
| Rate for Payer: Health EOS Commercial |
$3,956.94
|
| Rate for Payer: HFN Commercial |
$4,090.32
|
| Rate for Payer: Multiplan Commercial |
$3,556.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,090.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,178.54
|
| Rate for Payer: Quartz Commercial |
$2,667.60
|
| Rate for Payer: WEA Trust Commercial |
$2,445.30
|
| Rate for Payer: WPS Commercial |
$3,293.03
|
|
|
PLATE 2HH/4HS L -90 442.501
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,309.82 |
| Max. Negotiated Rate |
$4,303.69 |
| Rate for Payer: Aetna Commercial |
$4,210.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,309.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,040.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,338.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,245.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.30
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,303.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,617.84
|
| Rate for Payer: Health EOS Commercial |
$4,163.35
|
| Rate for Payer: HFN Commercial |
$4,303.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,508.44
|
| Rate for Payer: Multiplan Commercial |
$3,742.34
|
| Rate for Payer: NAPHCARE Commercial |
$2,806.75
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.18
|
| Rate for Payer: Quartz Commercial |
$3,040.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,806.75
|
| Rate for Payer: The Alliance Commercial |
$2,338.96
|
| Rate for Payer: WEA Trust Commercial |
$2,572.86
|
| Rate for Payer: WPS Commercial |
$3,464.81
|
|
|
PLATE 2HH/4HS L -90 442.501
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,292.18 |
| Max. Negotiated Rate |
$4,303.69 |
| Rate for Payer: Aetna Commercial |
$4,210.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.30
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,303.69
|
| Rate for Payer: Health EOS Commercial |
$4,163.35
|
| Rate for Payer: HFN Commercial |
$4,303.69
|
| Rate for Payer: Multiplan Commercial |
$3,742.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.18
|
| Rate for Payer: Quartz Commercial |
$2,806.75
|
| Rate for Payer: WEA Trust Commercial |
$2,572.86
|
| Rate for Payer: WPS Commercial |
$3,464.81
|
|
|
PLATE 2HH/4HS L +90 442.503
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,309.82 |
| Max. Negotiated Rate |
$4,303.69 |
| Rate for Payer: Aetna Commercial |
$4,210.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,309.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,040.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,338.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,245.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.30
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,303.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,617.84
|
| Rate for Payer: Health EOS Commercial |
$4,163.35
|
| Rate for Payer: HFN Commercial |
$4,303.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,508.44
|
| Rate for Payer: Multiplan Commercial |
$3,742.34
|
| Rate for Payer: NAPHCARE Commercial |
$2,806.75
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.18
|
| Rate for Payer: Quartz Commercial |
$3,040.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,806.75
|
| Rate for Payer: The Alliance Commercial |
$2,338.96
|
| Rate for Payer: WEA Trust Commercial |
$2,572.86
|
| Rate for Payer: WPS Commercial |
$3,464.81
|
|
|
PLATE 2HH/4HS L +90 442.503
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,292.18 |
| Max. Negotiated Rate |
$4,303.69 |
| Rate for Payer: Aetna Commercial |
$4,210.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.30
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,303.69
|
| Rate for Payer: Health EOS Commercial |
$4,163.35
|
| Rate for Payer: HFN Commercial |
$4,303.69
|
| Rate for Payer: Multiplan Commercial |
$3,742.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.18
|
| Rate for Payer: Quartz Commercial |
$2,806.75
|
| Rate for Payer: WEA Trust Commercial |
$2,572.86
|
| Rate for Payer: WPS Commercial |
$3,464.81
|
|
|
PLATE 2 HOLE STRAIGHT 52020302
|
Facility
|
OP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5957650
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,150.24 |
| Max. Negotiated Rate |
$3,779.36 |
| Rate for Payer: Aetna Commercial |
$3,697.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,532.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,150.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,670.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,054.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,971.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,177.24
|
| Rate for Payer: Cash Price |
$1,185.00
|
| Rate for Payer: Cigna Commercial |
$3,779.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,298.90
|
| Rate for Payer: Health EOS Commercial |
$3,656.12
|
| Rate for Payer: HFN Commercial |
$3,779.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,081.00
|
| Rate for Payer: Multiplan Commercial |
$3,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,464.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,779.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,012.92
|
| Rate for Payer: Quartz Commercial |
$2,670.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,464.80
|
| Rate for Payer: The Alliance Commercial |
$2,054.00
|
| Rate for Payer: WEA Trust Commercial |
$2,259.40
|
| Rate for Payer: WPS Commercial |
$3,042.68
|
|
|
PLATE 2 HOLE STRAIGHT 52020302
|
Facility
|
IP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5957650
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,012.92 |
| Max. Negotiated Rate |
$3,779.36 |
| Rate for Payer: Aetna Commercial |
$3,697.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,532.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,177.24
|
| Rate for Payer: Cash Price |
$1,185.00
|
| Rate for Payer: Cigna Commercial |
$3,779.36
|
| Rate for Payer: Health EOS Commercial |
$3,656.12
|
| Rate for Payer: HFN Commercial |
$3,779.36
|
| Rate for Payer: Multiplan Commercial |
$3,286.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,779.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,012.92
|
| Rate for Payer: Quartz Commercial |
$2,464.80
|
| Rate for Payer: WEA Trust Commercial |
$2,259.40
|
| Rate for Payer: WPS Commercial |
$3,042.68
|
|
|
PLATE 3.5 3HL LAT DIST HUMERUS
|
Facility
|
OP
|
$6,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,993.26 |
| Max. Negotiated Rate |
$6,549.30 |
| Rate for Payer: Aetna Commercial |
$6,406.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,122.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,993.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,627.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,559.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,417.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,772.96
|
| Rate for Payer: Cash Price |
$2,053.50
|
| Rate for Payer: Cigna Commercial |
$6,549.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,983.79
|
| Rate for Payer: Health EOS Commercial |
$6,335.73
|
| Rate for Payer: HFN Commercial |
$6,549.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,339.10
|
| Rate for Payer: Multiplan Commercial |
$5,695.04
|
| Rate for Payer: NAPHCARE Commercial |
$4,271.28
|
| Rate for Payer: Preferred Network Access Commercial |
$6,549.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,488.21
|
| Rate for Payer: Quartz Commercial |
$4,627.22
|
| Rate for Payer: Quartz Medicare Advantage |
$4,271.28
|
| Rate for Payer: The Alliance Commercial |
$3,559.40
|
| Rate for Payer: WEA Trust Commercial |
$3,915.34
|
| Rate for Payer: WPS Commercial |
$5,272.70
|
|
|
PLATE 3.5 3HL LAT DIST HUMERUS
|
Facility
|
IP
|
$6,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,488.21 |
| Max. Negotiated Rate |
$6,549.30 |
| Rate for Payer: Aetna Commercial |
$6,406.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,122.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,772.96
|
| Rate for Payer: Cash Price |
$2,053.50
|
| Rate for Payer: Cigna Commercial |
$6,549.30
|
| Rate for Payer: Health EOS Commercial |
$6,335.73
|
| Rate for Payer: HFN Commercial |
$6,549.30
|
| Rate for Payer: Multiplan Commercial |
$5,695.04
|
| Rate for Payer: Preferred Network Access Commercial |
$6,549.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,488.21
|
| Rate for Payer: Quartz Commercial |
$4,271.28
|
| Rate for Payer: WEA Trust Commercial |
$3,915.34
|
| Rate for Payer: WPS Commercial |
$5,272.70
|
|
|
PLATE 3.5 3HL MED DIST HUMERUS
|
Facility
|
OP
|
$6,496.00
|
|
| Hospital Charge Code |
2966333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,891.64 |
| Max. Negotiated Rate |
$6,215.37 |
| Rate for Payer: Aetna Commercial |
$6,080.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,810.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,891.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,391.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,377.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,242.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,580.60
|
| Rate for Payer: Cash Price |
$1,948.80
|
| Rate for Payer: Cigna Commercial |
$6,215.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,780.67
|
| Rate for Payer: Health EOS Commercial |
$6,012.70
|
| Rate for Payer: HFN Commercial |
$6,215.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,066.88
|
| Rate for Payer: Multiplan Commercial |
$5,404.67
|
| Rate for Payer: NAPHCARE Commercial |
$4,053.50
|
| Rate for Payer: Preferred Network Access Commercial |
$6,215.37
|
| Rate for Payer: Quartz Beloit One Network |
$3,310.36
|
| Rate for Payer: Quartz Commercial |
$4,391.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,053.50
|
| Rate for Payer: The Alliance Commercial |
$3,377.92
|
| Rate for Payer: WEA Trust Commercial |
$3,715.71
|
| Rate for Payer: WPS Commercial |
$5,003.87
|
|
|
PLATE 3.5 3HL MED DIST HUMERUS
|
Facility
|
IP
|
$6,496.00
|
|
| Hospital Charge Code |
2966333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,310.36 |
| Max. Negotiated Rate |
$6,215.37 |
| Rate for Payer: Aetna Commercial |
$6,080.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,810.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,580.60
|
| Rate for Payer: Cash Price |
$1,948.80
|
| Rate for Payer: Cigna Commercial |
$6,215.37
|
| Rate for Payer: Health EOS Commercial |
$6,012.70
|
| Rate for Payer: HFN Commercial |
$6,215.37
|
| Rate for Payer: Multiplan Commercial |
$5,404.67
|
| Rate for Payer: Preferred Network Access Commercial |
$6,215.37
|
| Rate for Payer: Quartz Beloit One Network |
$3,310.36
|
| Rate for Payer: Quartz Commercial |
$4,053.50
|
| Rate for Payer: WEA Trust Commercial |
$3,715.71
|
| Rate for Payer: WPS Commercial |
$5,003.87
|
|
|
PLATE 3.5 3-HOLE RT LCP 241.262
|
Facility
|
OP
|
$9,004.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,621.96 |
| Max. Negotiated Rate |
$8,615.03 |
| Rate for Payer: Aetna Commercial |
$8,427.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,053.18
|
| Rate for Payer: Aetna Managed Medicare |
$2,621.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,086.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,682.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,494.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,963.00
|
| Rate for Payer: Cash Price |
$2,701.20
|
| Rate for Payer: Cigna Commercial |
$8,615.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,240.33
|
| Rate for Payer: Health EOS Commercial |
$8,334.10
|
| Rate for Payer: HFN Commercial |
$8,615.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,023.12
|
| Rate for Payer: Multiplan Commercial |
$7,491.33
|
| Rate for Payer: NAPHCARE Commercial |
$5,618.50
|
| Rate for Payer: Preferred Network Access Commercial |
$8,615.03
|
| Rate for Payer: Quartz Beloit One Network |
$4,588.44
|
| Rate for Payer: Quartz Commercial |
$6,086.70
|
| Rate for Payer: Quartz Medicare Advantage |
$5,618.50
|
| Rate for Payer: The Alliance Commercial |
$4,682.08
|
| Rate for Payer: WEA Trust Commercial |
$5,150.29
|
| Rate for Payer: WPS Commercial |
$6,935.78
|
|
|
PLATE 3.5 3-HOLE RT LCP 241.262
|
Facility
|
IP
|
$9,004.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,588.44 |
| Max. Negotiated Rate |
$8,615.03 |
| Rate for Payer: Aetna Commercial |
$8,427.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,053.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,963.00
|
| Rate for Payer: Cash Price |
$2,701.20
|
| Rate for Payer: Cigna Commercial |
$8,615.03
|
| Rate for Payer: Health EOS Commercial |
$8,334.10
|
| Rate for Payer: HFN Commercial |
$8,615.03
|
| Rate for Payer: Multiplan Commercial |
$7,491.33
|
| Rate for Payer: Preferred Network Access Commercial |
$8,615.03
|
| Rate for Payer: Quartz Beloit One Network |
$4,588.44
|
| Rate for Payer: Quartz Commercial |
$5,618.50
|
| Rate for Payer: WEA Trust Commercial |
$5,150.29
|
| Rate for Payer: WPS Commercial |
$6,935.78
|
|
|
PLATE 3.5 5HL RT MED DIST HUM
|
Facility
|
OP
|
$6,631.00
|
|
| Hospital Charge Code |
2966337
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,930.95 |
| Max. Negotiated Rate |
$6,344.54 |
| Rate for Payer: Aetna Commercial |
$6,206.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,930.77
|
| Rate for Payer: Aetna Managed Medicare |
$1,930.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,482.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,448.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,310.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,655.01
|
| Rate for Payer: Cash Price |
$1,989.30
|
| Rate for Payer: Cigna Commercial |
$6,344.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,859.24
|
| Rate for Payer: Health EOS Commercial |
$6,137.65
|
| Rate for Payer: HFN Commercial |
$6,344.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,172.18
|
| Rate for Payer: Multiplan Commercial |
$5,516.99
|
| Rate for Payer: NAPHCARE Commercial |
$4,137.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,344.54
|
| Rate for Payer: Quartz Beloit One Network |
$3,379.16
|
| Rate for Payer: Quartz Commercial |
$4,482.56
|
| Rate for Payer: Quartz Medicare Advantage |
$4,137.74
|
| Rate for Payer: The Alliance Commercial |
$3,448.12
|
| Rate for Payer: WEA Trust Commercial |
$3,792.93
|
| Rate for Payer: WPS Commercial |
$5,107.86
|
|
