|
PLATE 3.5 5HL RT MED DIST HUM
|
Facility
|
IP
|
$6,631.00
|
|
| Hospital Charge Code |
2966337
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,379.16 |
| 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: 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: Health EOS Commercial |
$6,137.65
|
| Rate for Payer: HFN Commercial |
$6,344.54
|
| Rate for Payer: Multiplan Commercial |
$5,516.99
|
| 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 |
$4,137.74
|
| Rate for Payer: WEA Trust Commercial |
$3,792.93
|
| Rate for Payer: WPS Commercial |
$5,107.86
|
|
|
PLATE 3.5 7HL HOOK CLAVICLE 241.105S
|
Facility
|
IP
|
$8,595.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966339
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,380.01 |
| Max. Negotiated Rate |
$8,223.70 |
| Rate for Payer: Aetna Commercial |
$8,044.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,687.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,737.56
|
| Rate for Payer: Cash Price |
$2,578.50
|
| Rate for Payer: Cigna Commercial |
$8,223.70
|
| Rate for Payer: Health EOS Commercial |
$7,955.53
|
| Rate for Payer: HFN Commercial |
$8,223.70
|
| Rate for Payer: Multiplan Commercial |
$7,151.04
|
| Rate for Payer: Preferred Network Access Commercial |
$8,223.70
|
| Rate for Payer: Quartz Beloit One Network |
$4,380.01
|
| Rate for Payer: Quartz Commercial |
$5,363.28
|
| Rate for Payer: WEA Trust Commercial |
$4,916.34
|
| Rate for Payer: WPS Commercial |
$6,620.73
|
|
|
PLATE 3.5 7HL HOOK CLAVICLE 241.105S
|
Facility
|
OP
|
$8,595.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966339
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,502.86 |
| Max. Negotiated Rate |
$8,223.70 |
| Rate for Payer: Aetna Commercial |
$8,044.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,687.37
|
| Rate for Payer: Aetna Managed Medicare |
$2,502.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,810.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,469.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,290.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,737.56
|
| Rate for Payer: Cash Price |
$2,578.50
|
| Rate for Payer: Cigna Commercial |
$8,223.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,002.29
|
| Rate for Payer: Health EOS Commercial |
$7,955.53
|
| Rate for Payer: HFN Commercial |
$8,223.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,704.10
|
| Rate for Payer: Multiplan Commercial |
$7,151.04
|
| Rate for Payer: NAPHCARE Commercial |
$5,363.28
|
| Rate for Payer: Preferred Network Access Commercial |
$8,223.70
|
| Rate for Payer: Quartz Beloit One Network |
$4,380.01
|
| Rate for Payer: Quartz Commercial |
$5,810.22
|
| Rate for Payer: Quartz Medicare Advantage |
$5,363.28
|
| Rate for Payer: The Alliance Commercial |
$4,469.40
|
| Rate for Payer: WEA Trust Commercial |
$4,916.34
|
| Rate for Payer: WPS Commercial |
$6,620.73
|
|
|
PLATE 3.5 DISTAL HUMER 3HL LT
|
Facility
|
OP
|
$6,191.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,802.82 |
| Max. Negotiated Rate |
$5,923.55 |
| Rate for Payer: Aetna Commercial |
$5,794.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,537.23
|
| Rate for Payer: Aetna Managed Medicare |
$1,802.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,185.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,219.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,090.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,412.48
|
| Rate for Payer: Cash Price |
$1,857.30
|
| Rate for Payer: Cigna Commercial |
$5,923.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,603.16
|
| Rate for Payer: Health EOS Commercial |
$5,730.39
|
| Rate for Payer: HFN Commercial |
$5,923.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,828.98
|
| Rate for Payer: Multiplan Commercial |
$5,150.91
|
| Rate for Payer: NAPHCARE Commercial |
$3,863.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,923.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,154.93
|
| Rate for Payer: Quartz Commercial |
$4,185.12
|
| Rate for Payer: Quartz Medicare Advantage |
$3,863.18
|
| Rate for Payer: The Alliance Commercial |
$3,219.32
|
| Rate for Payer: WEA Trust Commercial |
$3,541.25
|
| Rate for Payer: WPS Commercial |
$4,768.93
|
|
|
PLATE 3.5 DISTAL HUMER 3HL LT
|
Facility
|
IP
|
$6,191.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,154.93 |
| Max. Negotiated Rate |
$5,923.55 |
| Rate for Payer: Aetna Commercial |
$5,794.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,537.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,412.48
|
| Rate for Payer: Cash Price |
$1,857.30
|
| Rate for Payer: Cigna Commercial |
$5,923.55
|
| Rate for Payer: Health EOS Commercial |
$5,730.39
|
| Rate for Payer: HFN Commercial |
$5,923.55
|
| Rate for Payer: Multiplan Commercial |
$5,150.91
|
| Rate for Payer: Preferred Network Access Commercial |
$5,923.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,154.93
|
| Rate for Payer: Quartz Commercial |
$3,863.18
|
| Rate for Payer: WEA Trust Commercial |
$3,541.25
|
| Rate for Payer: WPS Commercial |
$4,768.93
|
|
|
PLATE 3.5 LC-DCP 10HL 223.60
|
Facility
|
IP
|
$1,535.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966699
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$782.24 |
| Max. Negotiated Rate |
$1,468.69 |
| Rate for Payer: Aetna Commercial |
$1,436.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,372.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.09
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,468.69
|
| Rate for Payer: Health EOS Commercial |
$1,420.80
|
| Rate for Payer: HFN Commercial |
$1,468.69
|
| Rate for Payer: Multiplan Commercial |
$1,277.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,468.69
|
| Rate for Payer: Quartz Beloit One Network |
$782.24
|
| Rate for Payer: Quartz Commercial |
$957.84
|
| Rate for Payer: WEA Trust Commercial |
$878.02
|
| Rate for Payer: WPS Commercial |
$1,182.41
|
|
|
PLATE 3.5 LC-DCP 10HL 223.60
|
Facility
|
OP
|
$1,535.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966699
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$446.99 |
| Max. Negotiated Rate |
$1,468.69 |
| Rate for Payer: Aetna Commercial |
$1,436.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,372.90
|
| Rate for Payer: Aetna Managed Medicare |
$446.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,037.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$798.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$766.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.09
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,468.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$893.37
|
| Rate for Payer: Health EOS Commercial |
$1,420.80
|
| Rate for Payer: HFN Commercial |
$1,468.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,197.30
|
| Rate for Payer: Multiplan Commercial |
$1,277.12
|
| Rate for Payer: NAPHCARE Commercial |
$957.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,468.69
|
| Rate for Payer: Quartz Beloit One Network |
$782.24
|
| Rate for Payer: Quartz Commercial |
$1,037.66
|
| Rate for Payer: Quartz Medicare Advantage |
$957.84
|
| Rate for Payer: The Alliance Commercial |
$798.20
|
| Rate for Payer: WEA Trust Commercial |
$878.02
|
| Rate for Payer: WPS Commercial |
$1,182.41
|
|
|
PLATE 3.5 LC-DCP 12HL 223.62
|
Facility
|
IP
|
$1,660.00
|
|
| Hospital Charge Code |
2966700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.94 |
| Max. Negotiated Rate |
$1,588.29 |
| Rate for Payer: Aetna Commercial |
$1,553.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,484.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$914.99
|
| Rate for Payer: Cash Price |
$498.00
|
| Rate for Payer: Cigna Commercial |
$1,588.29
|
| Rate for Payer: Health EOS Commercial |
$1,536.50
|
| Rate for Payer: HFN Commercial |
$1,588.29
|
| Rate for Payer: Multiplan Commercial |
$1,381.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,588.29
|
| Rate for Payer: Quartz Beloit One Network |
$845.94
|
| Rate for Payer: Quartz Commercial |
$1,035.84
|
| Rate for Payer: WEA Trust Commercial |
$949.52
|
| Rate for Payer: WPS Commercial |
$1,278.70
|
|
|
PLATE 3.5 LC-DCP 12HL 223.62
|
Facility
|
OP
|
$1,660.00
|
|
| Hospital Charge Code |
2966700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$483.39 |
| Max. Negotiated Rate |
$1,588.29 |
| Rate for Payer: Aetna Commercial |
$1,553.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,484.70
|
| Rate for Payer: Aetna Managed Medicare |
$483.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,122.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$863.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$828.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$914.99
|
| Rate for Payer: Cash Price |
$498.00
|
| Rate for Payer: Cigna Commercial |
$1,588.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$966.12
|
| Rate for Payer: Health EOS Commercial |
$1,536.50
|
| Rate for Payer: HFN Commercial |
$1,588.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,294.80
|
| Rate for Payer: Multiplan Commercial |
$1,381.12
|
| Rate for Payer: NAPHCARE Commercial |
$1,035.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,588.29
|
| Rate for Payer: Quartz Beloit One Network |
$845.94
|
| Rate for Payer: Quartz Commercial |
$1,122.16
|
| Rate for Payer: Quartz Medicare Advantage |
$1,035.84
|
| Rate for Payer: The Alliance Commercial |
$863.20
|
| Rate for Payer: WEA Trust Commercial |
$949.52
|
| Rate for Payer: WPS Commercial |
$1,278.70
|
|
|
PLATE 3.5 LC-DCP 5HL 223.55
|
Facility
|
OP
|
$1,529.00
|
|
| Hospital Charge Code |
2966701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.24 |
| Max. Negotiated Rate |
$1,462.95 |
| Rate for Payer: Aetna Commercial |
$1,431.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,367.54
|
| Rate for Payer: Aetna Managed Medicare |
$445.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,033.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$795.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$763.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$842.78
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cigna Commercial |
$1,462.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$889.88
|
| Rate for Payer: Health EOS Commercial |
$1,415.24
|
| Rate for Payer: HFN Commercial |
$1,462.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,192.62
|
| Rate for Payer: Multiplan Commercial |
$1,272.13
|
| Rate for Payer: NAPHCARE Commercial |
$954.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,462.95
|
| Rate for Payer: Quartz Beloit One Network |
$779.18
|
| Rate for Payer: Quartz Commercial |
$1,033.60
|
| Rate for Payer: Quartz Medicare Advantage |
$954.10
|
| Rate for Payer: The Alliance Commercial |
$795.08
|
| Rate for Payer: WEA Trust Commercial |
$874.59
|
| Rate for Payer: WPS Commercial |
$1,177.79
|
|
|
PLATE 3.5 LC-DCP 5HL 223.55
|
Facility
|
IP
|
$1,529.00
|
|
| Hospital Charge Code |
2966701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$779.18 |
| Max. Negotiated Rate |
$1,462.95 |
| Rate for Payer: Aetna Commercial |
$1,431.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,367.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$842.78
|
| Rate for Payer: Cash Price |
$458.70
|
| Rate for Payer: Cigna Commercial |
$1,462.95
|
| Rate for Payer: Health EOS Commercial |
$1,415.24
|
| Rate for Payer: HFN Commercial |
$1,462.95
|
| Rate for Payer: Multiplan Commercial |
$1,272.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,462.95
|
| Rate for Payer: Quartz Beloit One Network |
$779.18
|
| Rate for Payer: Quartz Commercial |
$954.10
|
| Rate for Payer: WEA Trust Commercial |
$874.59
|
| Rate for Payer: WPS Commercial |
$1,177.79
|
|
|
PLATE 3.5 LC-DCP 6HL 223.56
|
Facility
|
OP
|
$1,968.00
|
|
| Hospital Charge Code |
2966621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$573.08 |
| Max. Negotiated Rate |
$1,882.98 |
| Rate for Payer: Aetna Commercial |
$1,842.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,760.18
|
| Rate for Payer: Aetna Managed Medicare |
$573.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,330.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,023.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$982.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,084.76
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Cigna Commercial |
$1,882.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,145.38
|
| Rate for Payer: Health EOS Commercial |
$1,821.58
|
| Rate for Payer: HFN Commercial |
$1,882.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,535.04
|
| Rate for Payer: Multiplan Commercial |
$1,637.38
|
| Rate for Payer: NAPHCARE Commercial |
$1,228.03
|
| Rate for Payer: Preferred Network Access Commercial |
$1,882.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,002.89
|
| Rate for Payer: Quartz Commercial |
$1,330.37
|
| Rate for Payer: Quartz Medicare Advantage |
$1,228.03
|
| Rate for Payer: The Alliance Commercial |
$1,023.36
|
| Rate for Payer: WEA Trust Commercial |
$1,125.70
|
| Rate for Payer: WPS Commercial |
$1,515.95
|
|
|
PLATE 3.5 LC-DCP 6HL 223.56
|
Facility
|
IP
|
$1,968.00
|
|
| Hospital Charge Code |
2966621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,002.89 |
| Max. Negotiated Rate |
$1,882.98 |
| Rate for Payer: Aetna Commercial |
$1,842.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,760.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,084.76
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Cigna Commercial |
$1,882.98
|
| Rate for Payer: Health EOS Commercial |
$1,821.58
|
| Rate for Payer: HFN Commercial |
$1,882.98
|
| Rate for Payer: Multiplan Commercial |
$1,637.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,882.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,002.89
|
| Rate for Payer: Quartz Commercial |
$1,228.03
|
| Rate for Payer: WEA Trust Commercial |
$1,125.70
|
| Rate for Payer: WPS Commercial |
$1,515.95
|
|
|
PLATE 3.5 LC-DCP 7HL 223.57
|
Facility
|
IP
|
$1,862.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.88 |
| Max. Negotiated Rate |
$1,781.56 |
| Rate for Payer: Aetna Commercial |
$1,742.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,665.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,026.33
|
| Rate for Payer: Cash Price |
$558.60
|
| Rate for Payer: Cigna Commercial |
$1,781.56
|
| Rate for Payer: Health EOS Commercial |
$1,723.47
|
| Rate for Payer: HFN Commercial |
$1,781.56
|
| Rate for Payer: Multiplan Commercial |
$1,549.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,781.56
|
| Rate for Payer: Quartz Beloit One Network |
$948.88
|
| Rate for Payer: Quartz Commercial |
$1,161.89
|
| Rate for Payer: WEA Trust Commercial |
$1,065.06
|
| Rate for Payer: WPS Commercial |
$1,434.30
|
|
|
PLATE 3.5 LC-DCP 7HL 223.57
|
Facility
|
OP
|
$1,862.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$542.21 |
| Max. Negotiated Rate |
$1,781.56 |
| Rate for Payer: Aetna Commercial |
$1,742.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,665.37
|
| Rate for Payer: Aetna Managed Medicare |
$542.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,258.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$968.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$929.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,026.33
|
| Rate for Payer: Cash Price |
$558.60
|
| Rate for Payer: Cigna Commercial |
$1,781.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,083.68
|
| Rate for Payer: Health EOS Commercial |
$1,723.47
|
| Rate for Payer: HFN Commercial |
$1,781.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,452.36
|
| Rate for Payer: Multiplan Commercial |
$1,549.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,161.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,781.56
|
| Rate for Payer: Quartz Beloit One Network |
$948.88
|
| Rate for Payer: Quartz Commercial |
$1,258.71
|
| Rate for Payer: Quartz Medicare Advantage |
$1,161.89
|
| Rate for Payer: The Alliance Commercial |
$968.24
|
| Rate for Payer: WEA Trust Commercial |
$1,065.06
|
| Rate for Payer: WPS Commercial |
$1,434.30
|
|
|
PLATE 3.5 LC-DCP 8HL 223.58
|
Facility
|
OP
|
$1,726.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966622
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$502.61 |
| Max. Negotiated Rate |
$1,651.44 |
| Rate for Payer: Aetna Commercial |
$1,615.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,543.73
|
| Rate for Payer: Aetna Managed Medicare |
$502.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,166.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$897.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$861.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$951.37
|
| Rate for Payer: Cash Price |
$517.80
|
| Rate for Payer: Cigna Commercial |
$1,651.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,004.53
|
| Rate for Payer: Health EOS Commercial |
$1,597.59
|
| Rate for Payer: HFN Commercial |
$1,651.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,346.28
|
| Rate for Payer: Multiplan Commercial |
$1,436.03
|
| Rate for Payer: NAPHCARE Commercial |
$1,077.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,651.44
|
| Rate for Payer: Quartz Beloit One Network |
$879.57
|
| Rate for Payer: Quartz Commercial |
$1,166.78
|
| Rate for Payer: Quartz Medicare Advantage |
$1,077.02
|
| Rate for Payer: The Alliance Commercial |
$897.52
|
| Rate for Payer: WEA Trust Commercial |
$987.27
|
| Rate for Payer: WPS Commercial |
$1,329.54
|
|
|
PLATE 3.5 LC-DCP 8HL 223.58
|
Facility
|
IP
|
$1,726.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966622
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$879.57 |
| Max. Negotiated Rate |
$1,651.44 |
| Rate for Payer: Aetna Commercial |
$1,615.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,543.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$951.37
|
| Rate for Payer: Cash Price |
$517.80
|
| Rate for Payer: Cigna Commercial |
$1,651.44
|
| Rate for Payer: Health EOS Commercial |
$1,597.59
|
| Rate for Payer: HFN Commercial |
$1,651.44
|
| Rate for Payer: Multiplan Commercial |
$1,436.03
|
| Rate for Payer: Preferred Network Access Commercial |
$1,651.44
|
| Rate for Payer: Quartz Beloit One Network |
$879.57
|
| Rate for Payer: Quartz Commercial |
$1,077.02
|
| Rate for Payer: WEA Trust Commercial |
$987.27
|
| Rate for Payer: WPS Commercial |
$1,329.54
|
|
|
PLATE 3.5 LCP MEDIAL/LATERAL ANTERIOR CLAVICLE 8HL 02.112.042S
|
Facility
|
OP
|
$6,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,800.78 |
| Max. Negotiated Rate |
$5,916.85 |
| Rate for Payer: Aetna Commercial |
$5,788.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,530.97
|
| Rate for Payer: Aetna Managed Medicare |
$1,800.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,180.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,215.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,087.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,408.62
|
| Rate for Payer: Cash Price |
$1,855.20
|
| Rate for Payer: Cigna Commercial |
$5,916.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,599.09
|
| Rate for Payer: Health EOS Commercial |
$5,723.91
|
| Rate for Payer: HFN Commercial |
$5,916.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,823.52
|
| Rate for Payer: Multiplan Commercial |
$5,145.09
|
| Rate for Payer: NAPHCARE Commercial |
$3,858.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,916.85
|
| Rate for Payer: Quartz Beloit One Network |
$3,151.37
|
| Rate for Payer: Quartz Commercial |
$4,180.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3,858.82
|
| Rate for Payer: The Alliance Commercial |
$3,215.68
|
| Rate for Payer: WEA Trust Commercial |
$3,537.25
|
| Rate for Payer: WPS Commercial |
$4,763.54
|
|
|
PLATE 3.5 LCP MEDIAL/LATERAL ANTERIOR CLAVICLE 8HL 02.112.042S
|
Facility
|
IP
|
$6,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,151.37 |
| Max. Negotiated Rate |
$5,916.85 |
| Rate for Payer: Aetna Commercial |
$5,788.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,530.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,408.62
|
| Rate for Payer: Cash Price |
$1,855.20
|
| Rate for Payer: Cigna Commercial |
$5,916.85
|
| Rate for Payer: Health EOS Commercial |
$5,723.91
|
| Rate for Payer: HFN Commercial |
$5,916.85
|
| Rate for Payer: Multiplan Commercial |
$5,145.09
|
| Rate for Payer: Preferred Network Access Commercial |
$5,916.85
|
| Rate for Payer: Quartz Beloit One Network |
$3,151.37
|
| Rate for Payer: Quartz Commercial |
$3,858.82
|
| Rate for Payer: WEA Trust Commercial |
$3,537.25
|
| Rate for Payer: WPS Commercial |
$4,763.54
|
|
|
PLATE 3.5MM LCP MED/DISTAL TIBIA 10 HL LT 02.112.523
|
Facility
|
IP
|
$6,868.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4208662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.93 |
| Max. Negotiated Rate |
$6,571.30 |
| Rate for Payer: Aetna Commercial |
$6,428.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,142.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,785.64
|
| Rate for Payer: Cash Price |
$2,060.40
|
| Rate for Payer: Cigna Commercial |
$6,571.30
|
| Rate for Payer: Health EOS Commercial |
$6,357.02
|
| Rate for Payer: HFN Commercial |
$6,571.30
|
| Rate for Payer: Multiplan Commercial |
$5,714.18
|
| Rate for Payer: Preferred Network Access Commercial |
$6,571.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,499.93
|
| Rate for Payer: Quartz Commercial |
$4,285.63
|
| Rate for Payer: WEA Trust Commercial |
$3,928.50
|
| Rate for Payer: WPS Commercial |
$5,290.42
|
|
|
PLATE 3.5MM LCP MED/DISTAL TIBIA 10 HL LT 02.112.523
|
Facility
|
OP
|
$6,868.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4208662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,999.96 |
| Max. Negotiated Rate |
$6,571.30 |
| Rate for Payer: Aetna Commercial |
$6,428.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,142.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,999.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,642.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,571.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,428.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,785.64
|
| Rate for Payer: Cash Price |
$2,060.40
|
| Rate for Payer: Cigna Commercial |
$6,571.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,997.18
|
| Rate for Payer: Health EOS Commercial |
$6,357.02
|
| Rate for Payer: HFN Commercial |
$6,571.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,357.04
|
| Rate for Payer: Multiplan Commercial |
$5,714.18
|
| Rate for Payer: NAPHCARE Commercial |
$4,285.63
|
| Rate for Payer: Preferred Network Access Commercial |
$6,571.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,499.93
|
| Rate for Payer: Quartz Commercial |
$4,642.77
|
| Rate for Payer: Quartz Medicare Advantage |
$4,285.63
|
| Rate for Payer: The Alliance Commercial |
$3,571.36
|
| Rate for Payer: WEA Trust Commercial |
$3,928.50
|
| Rate for Payer: WPS Commercial |
$5,290.42
|
|
|
PLATE 3.5MM LCP MED/DISTAL TIBIA 12 H LT 02.112.527
|
Facility
|
OP
|
$6,943.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4518751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,021.80 |
| Max. Negotiated Rate |
$6,643.06 |
| Rate for Payer: Aetna Commercial |
$6,498.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,209.82
|
| Rate for Payer: Aetna Managed Medicare |
$2,021.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,693.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,610.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,465.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,826.98
|
| Rate for Payer: Cash Price |
$2,082.90
|
| Rate for Payer: Cigna Commercial |
$6,643.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,040.83
|
| Rate for Payer: Health EOS Commercial |
$6,426.44
|
| Rate for Payer: HFN Commercial |
$6,643.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,415.54
|
| Rate for Payer: Multiplan Commercial |
$5,776.58
|
| Rate for Payer: NAPHCARE Commercial |
$4,332.43
|
| Rate for Payer: Preferred Network Access Commercial |
$6,643.06
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.15
|
| Rate for Payer: Quartz Commercial |
$4,693.47
|
| Rate for Payer: Quartz Medicare Advantage |
$4,332.43
|
| Rate for Payer: The Alliance Commercial |
$3,610.36
|
| Rate for Payer: WEA Trust Commercial |
$3,971.40
|
| Rate for Payer: WPS Commercial |
$5,348.19
|
|
|
PLATE 3.5MM LCP MED/DISTAL TIBIA 12 H LT 02.112.527
|
Facility
|
IP
|
$6,943.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4518751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,538.15 |
| Max. Negotiated Rate |
$6,643.06 |
| Rate for Payer: Aetna Commercial |
$6,498.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,209.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,826.98
|
| Rate for Payer: Cash Price |
$2,082.90
|
| Rate for Payer: Cigna Commercial |
$6,643.06
|
| Rate for Payer: Health EOS Commercial |
$6,426.44
|
| Rate for Payer: HFN Commercial |
$6,643.06
|
| Rate for Payer: Multiplan Commercial |
$5,776.58
|
| Rate for Payer: Preferred Network Access Commercial |
$6,643.06
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.15
|
| Rate for Payer: Quartz Commercial |
$4,332.43
|
| Rate for Payer: WEA Trust Commercial |
$3,971.40
|
| Rate for Payer: WPS Commercial |
$5,348.19
|
|
|
PLATE 3.5MM LCP SUPERIOR ANTERIOR CLAVICLE W LATERAL EXT 4HL LT 81MM 02.121.011S
|
Facility
|
IP
|
$6,203.00
|
|
| Hospital Charge Code |
2966336
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,161.05 |
| Max. Negotiated Rate |
$5,935.03 |
| Rate for Payer: Aetna Commercial |
$5,806.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,419.09
|
| Rate for Payer: Cash Price |
$1,860.90
|
| Rate for Payer: Cigna Commercial |
$5,935.03
|
| Rate for Payer: Health EOS Commercial |
$5,741.50
|
| Rate for Payer: HFN Commercial |
$5,935.03
|
| Rate for Payer: Multiplan Commercial |
$5,160.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,935.03
|
| Rate for Payer: Quartz Beloit One Network |
$3,161.05
|
| Rate for Payer: Quartz Commercial |
$3,870.67
|
| Rate for Payer: WEA Trust Commercial |
$3,548.12
|
| Rate for Payer: WPS Commercial |
$4,778.17
|
|
|
PLATE 3.5MM LCP SUPERIOR ANTERIOR CLAVICLE W LATERAL EXT 4HL LT 81MM 02.121.011S
|
Facility
|
OP
|
$6,203.00
|
|
| Hospital Charge Code |
2966336
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,806.31 |
| Max. Negotiated Rate |
$5,935.03 |
| Rate for Payer: Aetna Commercial |
$5,806.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,806.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,193.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,225.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,096.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,419.09
|
| Rate for Payer: Cash Price |
$1,860.90
|
| Rate for Payer: Cigna Commercial |
$5,935.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,610.15
|
| Rate for Payer: Health EOS Commercial |
$5,741.50
|
| Rate for Payer: HFN Commercial |
$5,935.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,838.34
|
| Rate for Payer: Multiplan Commercial |
$5,160.90
|
| Rate for Payer: NAPHCARE Commercial |
$3,870.67
|
| Rate for Payer: Preferred Network Access Commercial |
$5,935.03
|
| Rate for Payer: Quartz Beloit One Network |
$3,161.05
|
| Rate for Payer: Quartz Commercial |
$4,193.23
|
| Rate for Payer: Quartz Medicare Advantage |
$3,870.67
|
| Rate for Payer: The Alliance Commercial |
$3,225.56
|
| Rate for Payer: WEA Trust Commercial |
$3,548.12
|
| Rate for Payer: WPS Commercial |
$4,778.17
|
|
