|
PLATE 3HH/3HS L -20 442.511
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990951
|
|
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 3HH/3HS L +90 442.504
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966714
|
|
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 3HH/3HS L +90 442.504
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966714
|
|
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 3HH/3HS L -90 442.506
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990948
|
|
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 3HH/3HS L -90 442.506
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990948
|
|
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 3HH/4HS L +20 442.509
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990950
|
|
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 3HH/4HS L +20 442.509
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990950
|
|
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 3HH/4HS L -20 442.512
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966715
|
|
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 3HH/4HS L -20 442.512
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966715
|
|
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 3HH/4HS L +90 442.505
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966716
|
|
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 3HH/4HS L +90 442.505
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966716
|
|
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 3HH/4HS L -90 442.507
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990949
|
|
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 3HH/4HS L -90 442.507
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990949
|
|
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 4.5 CONDYLAR CRV 14HL RT 02.124.414S
|
Facility
|
IP
|
$8,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3181484
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,546.14 |
| Max. Negotiated Rate |
$8,535.61 |
| Rate for Payer: Aetna Commercial |
$8,350.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,978.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,917.26
|
| Rate for Payer: Cash Price |
$2,676.30
|
| Rate for Payer: Cigna Commercial |
$8,535.61
|
| Rate for Payer: Health EOS Commercial |
$8,257.28
|
| Rate for Payer: HFN Commercial |
$8,535.61
|
| Rate for Payer: Multiplan Commercial |
$7,422.27
|
| Rate for Payer: Preferred Network Access Commercial |
$8,535.61
|
| Rate for Payer: Quartz Beloit One Network |
$4,546.14
|
| Rate for Payer: Quartz Commercial |
$5,566.70
|
| Rate for Payer: WEA Trust Commercial |
$5,102.81
|
| Rate for Payer: WPS Commercial |
$6,871.85
|
|
|
PLATE 4.5 CONDYLAR CRV 14HL RT 02.124.414S
|
Facility
|
OP
|
$8,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3181484
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,597.80 |
| Max. Negotiated Rate |
$8,535.61 |
| Rate for Payer: Aetna Commercial |
$8,350.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,978.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,597.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,030.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,638.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,453.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,917.26
|
| Rate for Payer: Cash Price |
$2,676.30
|
| Rate for Payer: Cigna Commercial |
$8,535.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,192.02
|
| Rate for Payer: Health EOS Commercial |
$8,257.28
|
| Rate for Payer: HFN Commercial |
$8,535.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,958.38
|
| Rate for Payer: Multiplan Commercial |
$7,422.27
|
| Rate for Payer: NAPHCARE Commercial |
$5,566.70
|
| Rate for Payer: Preferred Network Access Commercial |
$8,535.61
|
| Rate for Payer: Quartz Beloit One Network |
$4,546.14
|
| Rate for Payer: Quartz Commercial |
$6,030.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,566.70
|
| Rate for Payer: The Alliance Commercial |
$4,638.92
|
| Rate for Payer: WEA Trust Commercial |
$5,102.81
|
| Rate for Payer: WPS Commercial |
$6,871.85
|
|
|
PLATE 4.5MM VA CURVED CONDYLAR 02.124.416
|
Facility
|
OP
|
$9,088.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5799777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,646.43 |
| Max. Negotiated Rate |
$8,695.40 |
| Rate for Payer: Aetna Commercial |
$8,506.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,128.31
|
| Rate for Payer: Aetna Managed Medicare |
$2,646.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,143.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,725.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,536.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.31
|
| Rate for Payer: Cash Price |
$2,726.40
|
| Rate for Payer: Cigna Commercial |
$8,695.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,289.22
|
| Rate for Payer: Health EOS Commercial |
$8,411.85
|
| Rate for Payer: HFN Commercial |
$8,695.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,088.64
|
| Rate for Payer: Multiplan Commercial |
$7,561.22
|
| Rate for Payer: NAPHCARE Commercial |
$5,670.91
|
| Rate for Payer: Preferred Network Access Commercial |
$8,695.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.24
|
| Rate for Payer: Quartz Commercial |
$6,143.49
|
| Rate for Payer: Quartz Medicare Advantage |
$5,670.91
|
| Rate for Payer: The Alliance Commercial |
$4,725.76
|
| Rate for Payer: WEA Trust Commercial |
$5,198.34
|
| Rate for Payer: WPS Commercial |
$7,000.49
|
|
|
PLATE 4.5MM VA CURVED CONDYLAR 02.124.416
|
Facility
|
IP
|
$9,088.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5799777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,631.24 |
| Max. Negotiated Rate |
$8,695.40 |
| Rate for Payer: Aetna Commercial |
$8,506.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,128.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.31
|
| Rate for Payer: Cash Price |
$2,726.40
|
| Rate for Payer: Cigna Commercial |
$8,695.40
|
| Rate for Payer: Health EOS Commercial |
$8,411.85
|
| Rate for Payer: HFN Commercial |
$8,695.40
|
| Rate for Payer: Multiplan Commercial |
$7,561.22
|
| Rate for Payer: Preferred Network Access Commercial |
$8,695.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.24
|
| Rate for Payer: Quartz Commercial |
$5,670.91
|
| Rate for Payer: WEA Trust Commercial |
$5,198.34
|
| Rate for Payer: WPS Commercial |
$7,000.49
|
|
|
PLATE 4.5 NARROW 14HL 224.641
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE 4.5 NARROW 14HL 224.641
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE 4.5 NARROW 16HL 224.661
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE 4.5 NARROW 16HL 224.661
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE 4.5 PROX FEMUR 6HL RT
|
Facility
|
OP
|
$9,274.00
|
|
| Hospital Charge Code |
2966346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,700.59 |
| Max. Negotiated Rate |
$8,873.36 |
| Rate for Payer: Aetna Commercial |
$8,680.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,294.67
|
| Rate for Payer: Aetna Managed Medicare |
$2,700.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,269.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,822.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,629.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,111.83
|
| Rate for Payer: Cash Price |
$2,782.20
|
| Rate for Payer: Cigna Commercial |
$8,873.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,397.47
|
| Rate for Payer: Health EOS Commercial |
$8,584.01
|
| Rate for Payer: HFN Commercial |
$8,873.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,233.72
|
| Rate for Payer: Multiplan Commercial |
$7,715.97
|
| Rate for Payer: NAPHCARE Commercial |
$5,786.98
|
| Rate for Payer: Preferred Network Access Commercial |
$8,873.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,726.03
|
| Rate for Payer: Quartz Commercial |
$6,269.22
|
| Rate for Payer: Quartz Medicare Advantage |
$5,786.98
|
| Rate for Payer: The Alliance Commercial |
$4,822.48
|
| Rate for Payer: WEA Trust Commercial |
$5,304.73
|
| Rate for Payer: WPS Commercial |
$7,143.76
|
|
|
PLATE 4.5 PROX FEMUR 6HL RT
|
Facility
|
IP
|
$9,274.00
|
|
| Hospital Charge Code |
2966346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,726.03 |
| Max. Negotiated Rate |
$8,873.36 |
| Rate for Payer: Aetna Commercial |
$8,680.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,294.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,111.83
|
| Rate for Payer: Cash Price |
$2,782.20
|
| Rate for Payer: Cigna Commercial |
$8,873.36
|
| Rate for Payer: Health EOS Commercial |
$8,584.01
|
| Rate for Payer: HFN Commercial |
$8,873.36
|
| Rate for Payer: Multiplan Commercial |
$7,715.97
|
| Rate for Payer: Preferred Network Access Commercial |
$8,873.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,726.03
|
| Rate for Payer: Quartz Commercial |
$5,786.98
|
| Rate for Payer: WEA Trust Commercial |
$5,304.73
|
| Rate for Payer: WPS Commercial |
$7,143.76
|
|
|
PLATE 4H 4H RT ANGLE T 241.141
|
Facility
|
IP
|
$1,379.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$702.74 |
| Max. Negotiated Rate |
$1,319.43 |
| Rate for Payer: Aetna Commercial |
$1,290.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,233.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$760.10
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cigna Commercial |
$1,319.43
|
| Rate for Payer: Health EOS Commercial |
$1,276.40
|
| Rate for Payer: HFN Commercial |
$1,319.43
|
| Rate for Payer: Multiplan Commercial |
$1,147.33
|
| Rate for Payer: Preferred Network Access Commercial |
$1,319.43
|
| Rate for Payer: Quartz Beloit One Network |
$702.74
|
| Rate for Payer: Quartz Commercial |
$860.50
|
| Rate for Payer: WEA Trust Commercial |
$788.79
|
| Rate for Payer: WPS Commercial |
$1,062.24
|
|
|
PLATE 4H 4H RT ANGLE T 241.141
|
Facility
|
OP
|
$1,379.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$401.56 |
| Max. Negotiated Rate |
$1,319.43 |
| Rate for Payer: Aetna Commercial |
$1,290.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,233.38
|
| Rate for Payer: Aetna Managed Medicare |
$401.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$932.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$717.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$688.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$760.10
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cigna Commercial |
$1,319.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$802.58
|
| Rate for Payer: Health EOS Commercial |
$1,276.40
|
| Rate for Payer: HFN Commercial |
$1,319.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,075.62
|
| Rate for Payer: Multiplan Commercial |
$1,147.33
|
| Rate for Payer: NAPHCARE Commercial |
$860.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,319.43
|
| Rate for Payer: Quartz Beloit One Network |
$702.74
|
| Rate for Payer: Quartz Commercial |
$932.20
|
| Rate for Payer: Quartz Medicare Advantage |
$860.50
|
| Rate for Payer: The Alliance Commercial |
$717.08
|
| Rate for Payer: WEA Trust Commercial |
$788.79
|
| Rate for Payer: WPS Commercial |
$1,062.24
|
|
