|
PLATE 4H 6H RT ANGLE T 241.161
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$366.91 |
| Max. Negotiated Rate |
$688.90 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$449.28
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
PLATE 4H 6H RT ANGLE T 241.161
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$209.66 |
| Max. Negotiated Rate |
$688.90 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Aetna Managed Medicare |
$209.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$486.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$374.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$359.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$419.04
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$561.60
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: NAPHCARE Commercial |
$449.28
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$486.72
|
| Rate for Payer: Quartz Medicare Advantage |
$449.28
|
| Rate for Payer: The Alliance Commercial |
$374.40
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
PLATE 4HL 3.5 RT M/D/T 239.900
|
Facility
|
IP
|
$7,307.00
|
|
| Hospital Charge Code |
2966725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,723.65 |
| Max. Negotiated Rate |
$6,991.34 |
| Rate for Payer: Aetna Commercial |
$6,839.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,535.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,027.62
|
| Rate for Payer: Cash Price |
$2,192.10
|
| Rate for Payer: Cigna Commercial |
$6,991.34
|
| Rate for Payer: Health EOS Commercial |
$6,763.36
|
| Rate for Payer: HFN Commercial |
$6,991.34
|
| Rate for Payer: Multiplan Commercial |
$6,079.42
|
| Rate for Payer: Preferred Network Access Commercial |
$6,991.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,723.65
|
| Rate for Payer: Quartz Commercial |
$4,559.57
|
| Rate for Payer: WEA Trust Commercial |
$4,179.60
|
| Rate for Payer: WPS Commercial |
$5,628.58
|
|
|
PLATE 4HL 3.5 RT M/D/T 239.900
|
Facility
|
OP
|
$7,307.00
|
|
| Hospital Charge Code |
2966725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,127.80 |
| Max. Negotiated Rate |
$6,991.34 |
| Rate for Payer: Aetna Commercial |
$6,839.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,535.38
|
| Rate for Payer: Aetna Managed Medicare |
$2,127.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,939.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,799.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,647.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,027.62
|
| Rate for Payer: Cash Price |
$2,192.10
|
| Rate for Payer: Cigna Commercial |
$6,991.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,252.67
|
| Rate for Payer: Health EOS Commercial |
$6,763.36
|
| Rate for Payer: HFN Commercial |
$6,991.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,699.46
|
| Rate for Payer: Multiplan Commercial |
$6,079.42
|
| Rate for Payer: NAPHCARE Commercial |
$4,559.57
|
| Rate for Payer: Preferred Network Access Commercial |
$6,991.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,723.65
|
| Rate for Payer: Quartz Commercial |
$4,939.53
|
| Rate for Payer: Quartz Medicare Advantage |
$4,559.57
|
| Rate for Payer: The Alliance Commercial |
$3,799.64
|
| Rate for Payer: WEA Trust Commercial |
$4,179.60
|
| Rate for Payer: WPS Commercial |
$5,628.58
|
|
|
PLATE 4 HL/78MM DHS STANDARD
|
Facility
|
OP
|
$4,951.00
|
|
| Hospital Charge Code |
2966343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,441.73 |
| Max. Negotiated Rate |
$4,737.12 |
| Rate for Payer: Aetna Commercial |
$4,634.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,428.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,441.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,346.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,574.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,471.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,728.99
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,737.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,881.48
|
| Rate for Payer: Health EOS Commercial |
$4,582.65
|
| Rate for Payer: HFN Commercial |
$4,737.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,861.78
|
| Rate for Payer: Multiplan Commercial |
$4,119.23
|
| Rate for Payer: NAPHCARE Commercial |
$3,089.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,523.03
|
| Rate for Payer: Quartz Commercial |
$3,346.88
|
| Rate for Payer: Quartz Medicare Advantage |
$3,089.42
|
| Rate for Payer: The Alliance Commercial |
$2,574.52
|
| Rate for Payer: WEA Trust Commercial |
$2,831.97
|
| Rate for Payer: WPS Commercial |
$3,813.76
|
|
|
PLATE 4 HL/78MM DHS STANDARD
|
Facility
|
IP
|
$4,951.00
|
|
| Hospital Charge Code |
2966343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.03 |
| Max. Negotiated Rate |
$4,737.12 |
| Rate for Payer: Aetna Commercial |
$4,634.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,428.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,728.99
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,737.12
|
| Rate for Payer: Health EOS Commercial |
$4,582.65
|
| Rate for Payer: HFN Commercial |
$4,737.12
|
| Rate for Payer: Multiplan Commercial |
$4,119.23
|
| Rate for Payer: Preferred Network Access Commercial |
$4,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,523.03
|
| Rate for Payer: Quartz Commercial |
$3,089.42
|
| Rate for Payer: WEA Trust Commercial |
$2,831.97
|
| Rate for Payer: WPS Commercial |
$3,813.76
|
|
|
PLATE 4HL/RT DISTAL FIBULA 02.112.138
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966348
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,803.69 |
| Max. Negotiated Rate |
$5,926.42 |
| Rate for Payer: Aetna Commercial |
$5,797.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,539.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,803.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,187.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,220.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,092.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,414.13
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,926.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,604.91
|
| Rate for Payer: Health EOS Commercial |
$5,733.17
|
| Rate for Payer: HFN Commercial |
$5,926.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,831.32
|
| Rate for Payer: Multiplan Commercial |
$5,153.41
|
| Rate for Payer: NAPHCARE Commercial |
$3,865.06
|
| Rate for Payer: Preferred Network Access Commercial |
$5,926.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,156.46
|
| Rate for Payer: Quartz Commercial |
$4,187.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,865.06
|
| Rate for Payer: The Alliance Commercial |
$3,220.88
|
| Rate for Payer: WEA Trust Commercial |
$3,542.97
|
| Rate for Payer: WPS Commercial |
$4,771.24
|
|
|
PLATE 4HL/RT DISTAL FIBULA 02.112.138
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966348
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,156.46 |
| Max. Negotiated Rate |
$5,926.42 |
| Rate for Payer: Aetna Commercial |
$5,797.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,539.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,414.13
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,926.42
|
| Rate for Payer: Health EOS Commercial |
$5,733.17
|
| Rate for Payer: HFN Commercial |
$5,926.42
|
| Rate for Payer: Multiplan Commercial |
$5,153.41
|
| Rate for Payer: Preferred Network Access Commercial |
$5,926.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,156.46
|
| Rate for Payer: Quartz Commercial |
$3,865.06
|
| Rate for Payer: WEA Trust Commercial |
$3,542.97
|
| Rate for Payer: WPS Commercial |
$4,771.24
|
|
|
PLATE 4H LT MED/DIS/TI 239.901
|
Facility
|
IP
|
$5,084.00
|
|
| Hospital Charge Code |
2966723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,590.81 |
| Max. Negotiated Rate |
$4,864.37 |
| Rate for Payer: Aetna Commercial |
$4,758.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,547.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,802.30
|
| Rate for Payer: Cash Price |
$1,525.20
|
| Rate for Payer: Cigna Commercial |
$4,864.37
|
| Rate for Payer: Health EOS Commercial |
$4,705.75
|
| Rate for Payer: HFN Commercial |
$4,864.37
|
| Rate for Payer: Multiplan Commercial |
$4,229.89
|
| Rate for Payer: Preferred Network Access Commercial |
$4,864.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,590.81
|
| Rate for Payer: Quartz Commercial |
$3,172.42
|
| Rate for Payer: WEA Trust Commercial |
$2,908.05
|
| Rate for Payer: WPS Commercial |
$3,916.21
|
|
|
PLATE 4H LT MED/DIS/TI 239.901
|
Facility
|
OP
|
$5,084.00
|
|
| Hospital Charge Code |
2966723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,480.46 |
| Max. Negotiated Rate |
$4,864.37 |
| Rate for Payer: Aetna Commercial |
$4,758.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,547.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,480.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,436.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,643.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,537.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,802.30
|
| Rate for Payer: Cash Price |
$1,525.20
|
| Rate for Payer: Cigna Commercial |
$4,864.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,958.89
|
| Rate for Payer: Health EOS Commercial |
$4,705.75
|
| Rate for Payer: HFN Commercial |
$4,864.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,965.52
|
| Rate for Payer: Multiplan Commercial |
$4,229.89
|
| Rate for Payer: NAPHCARE Commercial |
$3,172.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,864.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,590.81
|
| Rate for Payer: Quartz Commercial |
$3,436.78
|
| Rate for Payer: Quartz Medicare Advantage |
$3,172.42
|
| Rate for Payer: The Alliance Commercial |
$2,643.68
|
| Rate for Payer: WEA Trust Commercial |
$2,908.05
|
| Rate for Payer: WPS Commercial |
$3,916.21
|
|
|
PLATE 4H LT PROX/TIB 240.037
|
Facility
|
IP
|
$4,572.00
|
|
| Hospital Charge Code |
2966722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,329.89 |
| Max. Negotiated Rate |
$4,374.49 |
| Rate for Payer: Aetna Commercial |
$4,279.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,089.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,520.09
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,374.49
|
| Rate for Payer: Health EOS Commercial |
$4,231.84
|
| Rate for Payer: HFN Commercial |
$4,374.49
|
| Rate for Payer: Multiplan Commercial |
$3,803.90
|
| Rate for Payer: Preferred Network Access Commercial |
$4,374.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,329.89
|
| Rate for Payer: Quartz Commercial |
$2,852.93
|
| Rate for Payer: WEA Trust Commercial |
$2,615.18
|
| Rate for Payer: WPS Commercial |
$3,521.81
|
|
|
PLATE 4H LT PROX/TIB 240.037
|
Facility
|
OP
|
$4,572.00
|
|
| Hospital Charge Code |
2966722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.37 |
| Max. Negotiated Rate |
$4,374.49 |
| Rate for Payer: Aetna Commercial |
$4,279.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,089.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,331.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,090.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,377.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,282.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,520.09
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,374.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,660.90
|
| Rate for Payer: Health EOS Commercial |
$4,231.84
|
| Rate for Payer: HFN Commercial |
$4,374.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,566.16
|
| Rate for Payer: Multiplan Commercial |
$3,803.90
|
| Rate for Payer: NAPHCARE Commercial |
$2,852.93
|
| Rate for Payer: Preferred Network Access Commercial |
$4,374.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,329.89
|
| Rate for Payer: Quartz Commercial |
$3,090.67
|
| Rate for Payer: Quartz Medicare Advantage |
$2,852.93
|
| Rate for Payer: The Alliance Commercial |
$2,377.44
|
| Rate for Payer: WEA Trust Commercial |
$2,615.18
|
| Rate for Payer: WPS Commercial |
$3,521.81
|
|
|
PLATE 4 HOLE LEFT
|
Facility
|
IP
|
$6,251.00
|
|
| Hospital Charge Code |
2966344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,185.51 |
| Max. Negotiated Rate |
$5,980.96 |
| Rate for Payer: Aetna Commercial |
$5,850.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,590.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,445.55
|
| Rate for Payer: Cash Price |
$1,875.30
|
| Rate for Payer: Cigna Commercial |
$5,980.96
|
| Rate for Payer: Health EOS Commercial |
$5,785.93
|
| Rate for Payer: HFN Commercial |
$5,980.96
|
| Rate for Payer: Multiplan Commercial |
$5,200.83
|
| Rate for Payer: Preferred Network Access Commercial |
$5,980.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,185.51
|
| Rate for Payer: Quartz Commercial |
$3,900.62
|
| Rate for Payer: WEA Trust Commercial |
$3,575.57
|
| Rate for Payer: WPS Commercial |
$4,815.15
|
|
|
PLATE 4 HOLE LEFT
|
Facility
|
OP
|
$6,251.00
|
|
| Hospital Charge Code |
2966344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,820.29 |
| Max. Negotiated Rate |
$5,980.96 |
| Rate for Payer: Aetna Commercial |
$5,850.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,590.89
|
| Rate for Payer: Aetna Managed Medicare |
$1,820.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,225.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,250.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,120.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,445.55
|
| Rate for Payer: Cash Price |
$1,875.30
|
| Rate for Payer: Cigna Commercial |
$5,980.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,638.08
|
| Rate for Payer: Health EOS Commercial |
$5,785.93
|
| Rate for Payer: HFN Commercial |
$5,980.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,875.78
|
| Rate for Payer: Multiplan Commercial |
$5,200.83
|
| Rate for Payer: NAPHCARE Commercial |
$3,900.62
|
| Rate for Payer: Preferred Network Access Commercial |
$5,980.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,185.51
|
| Rate for Payer: Quartz Commercial |
$4,225.68
|
| Rate for Payer: Quartz Medicare Advantage |
$3,900.62
|
| Rate for Payer: The Alliance Commercial |
$3,250.52
|
| Rate for Payer: WEA Trust Commercial |
$3,575.57
|
| Rate for Payer: WPS Commercial |
$4,815.15
|
|
|
PLATE 4 HOLE OLECRANON
|
Facility
|
OP
|
$8,637.00
|
|
| Hospital Charge Code |
2966345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,515.09 |
| Max. Negotiated Rate |
$8,263.88 |
| Rate for Payer: Aetna Commercial |
$8,084.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,724.93
|
| Rate for Payer: Aetna Managed Medicare |
$2,515.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,838.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,491.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,311.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,760.71
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cigna Commercial |
$8,263.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,026.73
|
| Rate for Payer: Health EOS Commercial |
$7,994.41
|
| Rate for Payer: HFN Commercial |
$8,263.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,736.86
|
| Rate for Payer: Multiplan Commercial |
$7,185.98
|
| Rate for Payer: NAPHCARE Commercial |
$5,389.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8,263.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,401.42
|
| Rate for Payer: Quartz Commercial |
$5,838.61
|
| Rate for Payer: Quartz Medicare Advantage |
$5,389.49
|
| Rate for Payer: The Alliance Commercial |
$4,491.24
|
| Rate for Payer: WEA Trust Commercial |
$4,940.36
|
| Rate for Payer: WPS Commercial |
$6,653.08
|
|
|
PLATE 4 HOLE OLECRANON
|
Facility
|
IP
|
$8,637.00
|
|
| Hospital Charge Code |
2966345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,401.42 |
| Max. Negotiated Rate |
$8,263.88 |
| Rate for Payer: Aetna Commercial |
$8,084.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,724.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,760.71
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cigna Commercial |
$8,263.88
|
| Rate for Payer: Health EOS Commercial |
$7,994.41
|
| Rate for Payer: HFN Commercial |
$8,263.88
|
| Rate for Payer: Multiplan Commercial |
$7,185.98
|
| Rate for Payer: Preferred Network Access Commercial |
$8,263.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,401.42
|
| Rate for Payer: Quartz Commercial |
$5,389.49
|
| Rate for Payer: WEA Trust Commercial |
$4,940.36
|
| Rate for Payer: WPS Commercial |
$6,653.08
|
|
|
PLATE 4H RT PROX/TIB 240.036
|
Facility
|
OP
|
$4,572.00
|
|
| Hospital Charge Code |
2966724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.37 |
| Max. Negotiated Rate |
$4,374.49 |
| Rate for Payer: Aetna Commercial |
$4,279.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,089.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,331.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,090.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,377.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,282.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,520.09
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,374.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,660.90
|
| Rate for Payer: Health EOS Commercial |
$4,231.84
|
| Rate for Payer: HFN Commercial |
$4,374.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,566.16
|
| Rate for Payer: Multiplan Commercial |
$3,803.90
|
| Rate for Payer: NAPHCARE Commercial |
$2,852.93
|
| Rate for Payer: Preferred Network Access Commercial |
$4,374.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,329.89
|
| Rate for Payer: Quartz Commercial |
$3,090.67
|
| Rate for Payer: Quartz Medicare Advantage |
$2,852.93
|
| Rate for Payer: The Alliance Commercial |
$2,377.44
|
| Rate for Payer: WEA Trust Commercial |
$2,615.18
|
| Rate for Payer: WPS Commercial |
$3,521.81
|
|
|
PLATE 4H RT PROX/TIB 240.036
|
Facility
|
IP
|
$4,572.00
|
|
| Hospital Charge Code |
2966724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,329.89 |
| Max. Negotiated Rate |
$4,374.49 |
| Rate for Payer: Aetna Commercial |
$4,279.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,089.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,520.09
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,374.49
|
| Rate for Payer: Health EOS Commercial |
$4,231.84
|
| Rate for Payer: HFN Commercial |
$4,374.49
|
| Rate for Payer: Multiplan Commercial |
$3,803.90
|
| Rate for Payer: Preferred Network Access Commercial |
$4,374.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,329.89
|
| Rate for Payer: Quartz Commercial |
$2,852.93
|
| Rate for Payer: WEA Trust Commercial |
$2,615.18
|
| Rate for Payer: WPS Commercial |
$3,521.81
|
|
|
PLATE 5H 3.5 LCP 223.551
|
Facility
|
IP
|
$1,249.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$636.49 |
| Max. Negotiated Rate |
$1,195.04 |
| Rate for Payer: Aetna Commercial |
$1,169.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,117.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$688.45
|
| Rate for Payer: Cash Price |
$374.70
|
| Rate for Payer: Cigna Commercial |
$1,195.04
|
| Rate for Payer: Health EOS Commercial |
$1,156.07
|
| Rate for Payer: HFN Commercial |
$1,195.04
|
| Rate for Payer: Multiplan Commercial |
$1,039.17
|
| Rate for Payer: Preferred Network Access Commercial |
$1,195.04
|
| Rate for Payer: Quartz Beloit One Network |
$636.49
|
| Rate for Payer: Quartz Commercial |
$779.38
|
| Rate for Payer: WEA Trust Commercial |
$714.43
|
| Rate for Payer: WPS Commercial |
$962.10
|
|
|
PLATE 5H 3.5 LCP 223.551
|
Facility
|
OP
|
$1,249.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$363.71 |
| Max. Negotiated Rate |
$1,195.04 |
| Rate for Payer: Aetna Commercial |
$1,169.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,117.11
|
| Rate for Payer: Aetna Managed Medicare |
$363.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$844.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$649.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$623.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$688.45
|
| Rate for Payer: Cash Price |
$374.70
|
| Rate for Payer: Cigna Commercial |
$1,195.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$726.92
|
| Rate for Payer: Health EOS Commercial |
$1,156.07
|
| Rate for Payer: HFN Commercial |
$1,195.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$974.22
|
| Rate for Payer: Multiplan Commercial |
$1,039.17
|
| Rate for Payer: NAPHCARE Commercial |
$779.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,195.04
|
| Rate for Payer: Quartz Beloit One Network |
$636.49
|
| Rate for Payer: Quartz Commercial |
$844.32
|
| Rate for Payer: Quartz Medicare Advantage |
$779.38
|
| Rate for Payer: The Alliance Commercial |
$649.48
|
| Rate for Payer: WEA Trust Commercial |
$714.43
|
| Rate for Payer: WPS Commercial |
$962.10
|
|
|
PLATE 5H 3.5 LCP RECON 245.051
|
Facility
|
IP
|
$1,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$940.21 |
| Max. Negotiated Rate |
$1,765.30 |
| Rate for Payer: Aetna Commercial |
$1,726.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,650.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,016.96
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cigna Commercial |
$1,765.30
|
| Rate for Payer: Health EOS Commercial |
$1,707.73
|
| Rate for Payer: HFN Commercial |
$1,765.30
|
| Rate for Payer: Multiplan Commercial |
$1,535.04
|
| Rate for Payer: Preferred Network Access Commercial |
$1,765.30
|
| Rate for Payer: Quartz Beloit One Network |
$940.21
|
| Rate for Payer: Quartz Commercial |
$1,151.28
|
| Rate for Payer: WEA Trust Commercial |
$1,055.34
|
| Rate for Payer: WPS Commercial |
$1,421.20
|
|
|
PLATE 5H 3.5 LCP RECON 245.051
|
Facility
|
OP
|
$1,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$537.26 |
| Max. Negotiated Rate |
$1,765.30 |
| Rate for Payer: Aetna Commercial |
$1,726.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,650.17
|
| Rate for Payer: Aetna Managed Medicare |
$537.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,247.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$959.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$921.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,016.96
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cigna Commercial |
$1,765.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,073.79
|
| Rate for Payer: Health EOS Commercial |
$1,707.73
|
| Rate for Payer: HFN Commercial |
$1,765.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,439.10
|
| Rate for Payer: Multiplan Commercial |
$1,535.04
|
| Rate for Payer: NAPHCARE Commercial |
$1,151.28
|
| Rate for Payer: Preferred Network Access Commercial |
$1,765.30
|
| Rate for Payer: Quartz Beloit One Network |
$940.21
|
| Rate for Payer: Quartz Commercial |
$1,247.22
|
| Rate for Payer: Quartz Medicare Advantage |
$1,151.28
|
| Rate for Payer: The Alliance Commercial |
$959.40
|
| Rate for Payer: WEA Trust Commercial |
$1,055.34
|
| Rate for Payer: WPS Commercial |
$1,421.20
|
|
|
PLATE 5 HL DISTAL FEMUR RT
|
Facility
|
OP
|
$2,924.00
|
|
| Hospital Charge Code |
2966349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$851.47 |
| Max. Negotiated Rate |
$2,797.68 |
| Rate for Payer: Aetna Commercial |
$2,736.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,615.23
|
| Rate for Payer: Aetna Managed Medicare |
$851.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,976.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,520.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,459.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,611.71
|
| Rate for Payer: Cash Price |
$877.20
|
| Rate for Payer: Cigna Commercial |
$2,797.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,701.77
|
| Rate for Payer: Health EOS Commercial |
$2,706.45
|
| Rate for Payer: HFN Commercial |
$2,797.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,280.72
|
| Rate for Payer: Multiplan Commercial |
$2,432.77
|
| Rate for Payer: NAPHCARE Commercial |
$1,824.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,797.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,490.07
|
| Rate for Payer: Quartz Commercial |
$1,976.62
|
| Rate for Payer: Quartz Medicare Advantage |
$1,824.58
|
| Rate for Payer: The Alliance Commercial |
$1,520.48
|
| Rate for Payer: WEA Trust Commercial |
$1,672.53
|
| Rate for Payer: WPS Commercial |
$2,252.36
|
|
|
PLATE 5 HL DISTAL FEMUR RT
|
Facility
|
IP
|
$2,924.00
|
|
| Hospital Charge Code |
2966349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,490.07 |
| Max. Negotiated Rate |
$2,797.68 |
| Rate for Payer: Aetna Commercial |
$2,736.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,615.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,611.71
|
| Rate for Payer: Cash Price |
$877.20
|
| Rate for Payer: Cigna Commercial |
$2,797.68
|
| Rate for Payer: Health EOS Commercial |
$2,706.45
|
| Rate for Payer: HFN Commercial |
$2,797.68
|
| Rate for Payer: Multiplan Commercial |
$2,432.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,797.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,490.07
|
| Rate for Payer: Quartz Commercial |
$1,824.58
|
| Rate for Payer: WEA Trust Commercial |
$1,672.53
|
| Rate for Payer: WPS Commercial |
$2,252.36
|
|
|
PLATE 5 HL LT MEDIAL DISTAL
|
Facility
|
OP
|
$6,869.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966350
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,000.25 |
| Max. Negotiated Rate |
$6,572.26 |
| Rate for Payer: Aetna Commercial |
$6,429.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,143.63
|
| Rate for Payer: Aetna Managed Medicare |
$2,000.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,643.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,571.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,429.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,786.19
|
| Rate for Payer: Cash Price |
$2,060.70
|
| Rate for Payer: Cigna Commercial |
$6,572.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,997.76
|
| Rate for Payer: Health EOS Commercial |
$6,357.95
|
| Rate for Payer: HFN Commercial |
$6,572.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,357.82
|
| Rate for Payer: Multiplan Commercial |
$5,715.01
|
| Rate for Payer: NAPHCARE Commercial |
$4,286.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,572.26
|
| Rate for Payer: Quartz Beloit One Network |
$3,500.44
|
| Rate for Payer: Quartz Commercial |
$4,643.44
|
| Rate for Payer: Quartz Medicare Advantage |
$4,286.26
|
| Rate for Payer: The Alliance Commercial |
$3,571.88
|
| Rate for Payer: WEA Trust Commercial |
$3,929.07
|
| Rate for Payer: WPS Commercial |
$5,291.19
|
|
