|
Plastic mod low ext pad/line L2275
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
HCPCS L2275
|
| Hospital Charge Code |
4524748
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$226.77 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, KELLY URETHRAL PLICATION)
|
Facility
|
OP
|
$21,058.09
|
|
|
Service Code
|
CPT 57220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$21,058.09 |
| Rate for Payer: Aetna Managed Medicare |
$5,264.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$5,264.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,264.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,264.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,264.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,264.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,584.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,264.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,264.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,264.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,264.52
|
| Rate for Payer: NAPHCARE Commercial |
$7,896.78
|
| Rate for Payer: Quartz Medicare Advantage |
$5,264.52
|
| Rate for Payer: The Alliance Commercial |
$21,058.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,264.52
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: Wellcare Medicare |
$5,264.52
|
|
|
PLASTO FIX
|
Facility
|
IP
|
$675.00
|
|
| Hospital Charge Code |
2971519
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$343.98 |
| Max. Negotiated Rate |
$645.84 |
| Rate for Payer: Aetna Commercial |
$631.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$603.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.06
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$645.84
|
| Rate for Payer: Health EOS Commercial |
$624.78
|
| Rate for Payer: HFN Commercial |
$645.84
|
| Rate for Payer: Multiplan Commercial |
$561.60
|
| Rate for Payer: Preferred Network Access Commercial |
$645.84
|
| Rate for Payer: Quartz Beloit One Network |
$343.98
|
| Rate for Payer: Quartz Commercial |
$421.20
|
| Rate for Payer: WEA Trust Commercial |
$386.10
|
| Rate for Payer: WPS Commercial |
$519.95
|
|
|
PLASTO FIX
|
Facility
|
OP
|
$675.00
|
|
| Hospital Charge Code |
2971519
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$196.56 |
| Max. Negotiated Rate |
$645.84 |
| Rate for Payer: Aetna Commercial |
$631.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$603.72
|
| Rate for Payer: Aetna Managed Medicare |
$196.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$456.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$351.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$336.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.06
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$645.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$392.85
|
| Rate for Payer: Health EOS Commercial |
$624.78
|
| Rate for Payer: HFN Commercial |
$645.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$526.50
|
| Rate for Payer: Multiplan Commercial |
$561.60
|
| Rate for Payer: NAPHCARE Commercial |
$421.20
|
| Rate for Payer: Preferred Network Access Commercial |
$645.84
|
| Rate for Payer: Quartz Beloit One Network |
$343.98
|
| Rate for Payer: Quartz Commercial |
$456.30
|
| Rate for Payer: Quartz Medicare Advantage |
$421.20
|
| Rate for Payer: The Alliance Commercial |
$351.00
|
| Rate for Payer: WEA Trust Commercial |
$386.10
|
| Rate for Payer: WPS Commercial |
$519.95
|
|
|
PLATE 10H 3.5 LCP 223.601
|
Facility
|
IP
|
$1,623.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$827.08 |
| Max. Negotiated Rate |
$1,552.89 |
| Rate for Payer: HFN Commercial |
$1,552.89
|
| Rate for Payer: Aetna Commercial |
$1,519.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,451.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$894.60
|
| Rate for Payer: Cash Price |
$486.90
|
| Rate for Payer: Cigna Commercial |
$1,552.89
|
| Rate for Payer: Health EOS Commercial |
$1,502.25
|
| Rate for Payer: Multiplan Commercial |
$1,350.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,552.89
|
| Rate for Payer: Quartz Beloit One Network |
$827.08
|
| Rate for Payer: Quartz Commercial |
$1,012.75
|
| Rate for Payer: WEA Trust Commercial |
$928.36
|
| Rate for Payer: WPS Commercial |
$1,250.20
|
|
|
PLATE 10H 3.5 LCP 223.601
|
Facility
|
OP
|
$1,623.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$472.62 |
| Max. Negotiated Rate |
$1,552.89 |
| Rate for Payer: Aetna Commercial |
$1,519.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,451.61
|
| Rate for Payer: Aetna Managed Medicare |
$472.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,097.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$843.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$810.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$894.60
|
| Rate for Payer: Cash Price |
$486.90
|
| Rate for Payer: Cigna Commercial |
$1,552.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$944.59
|
| Rate for Payer: Health EOS Commercial |
$1,502.25
|
| Rate for Payer: HFN Commercial |
$1,552.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,265.94
|
| Rate for Payer: Multiplan Commercial |
$1,350.34
|
| Rate for Payer: NAPHCARE Commercial |
$1,012.75
|
| Rate for Payer: Preferred Network Access Commercial |
$1,552.89
|
| Rate for Payer: Quartz Beloit One Network |
$827.08
|
| Rate for Payer: Quartz Commercial |
$1,097.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,012.75
|
| Rate for Payer: The Alliance Commercial |
$843.96
|
| Rate for Payer: WEA Trust Commercial |
$928.36
|
| Rate for Payer: WPS Commercial |
$1,250.20
|
|
|
PLATE 10H 3.5 LCP RECON 245.101
|
Facility
|
IP
|
$2,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,232.72 |
| Max. Negotiated Rate |
$2,314.50 |
| Rate for Payer: Aetna Commercial |
$2,264.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,163.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,333.35
|
| Rate for Payer: Cash Price |
$725.70
|
| Rate for Payer: Cigna Commercial |
$2,314.50
|
| Rate for Payer: Health EOS Commercial |
$2,239.03
|
| Rate for Payer: HFN Commercial |
$2,314.50
|
| Rate for Payer: Multiplan Commercial |
$2,012.61
|
| Rate for Payer: Preferred Network Access Commercial |
$2,314.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,232.72
|
| Rate for Payer: Quartz Commercial |
$1,509.46
|
| Rate for Payer: WEA Trust Commercial |
$1,383.67
|
| Rate for Payer: WPS Commercial |
$1,863.36
|
|
|
PLATE 10H 3.5 LCP RECON 245.101
|
Facility
|
OP
|
$2,419.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$704.41 |
| Max. Negotiated Rate |
$2,314.50 |
| Rate for Payer: Aetna Commercial |
$2,264.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,163.55
|
| Rate for Payer: Aetna Managed Medicare |
$704.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,635.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,257.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,207.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,333.35
|
| Rate for Payer: Cash Price |
$725.70
|
| Rate for Payer: Cigna Commercial |
$2,314.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,407.86
|
| Rate for Payer: Health EOS Commercial |
$2,239.03
|
| Rate for Payer: HFN Commercial |
$2,314.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,886.82
|
| Rate for Payer: Multiplan Commercial |
$2,012.61
|
| Rate for Payer: NAPHCARE Commercial |
$1,509.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,314.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,232.72
|
| Rate for Payer: Quartz Commercial |
$1,635.24
|
| Rate for Payer: Quartz Medicare Advantage |
$1,509.46
|
| Rate for Payer: The Alliance Commercial |
$1,257.88
|
| Rate for Payer: WEA Trust Commercial |
$1,383.67
|
| Rate for Payer: WPS Commercial |
$1,863.36
|
|
|
PLATE 10 HL 1/3 COLLAR 121mm
|
Facility
|
IP
|
$5,386.00
|
|
| Hospital Charge Code |
2966317
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,744.71 |
| Max. Negotiated Rate |
$5,153.32 |
| Rate for Payer: Aetna Commercial |
$5,041.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,817.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,968.76
|
| Rate for Payer: Cash Price |
$1,615.80
|
| Rate for Payer: Cigna Commercial |
$5,153.32
|
| Rate for Payer: Health EOS Commercial |
$4,985.28
|
| Rate for Payer: HFN Commercial |
$5,153.32
|
| Rate for Payer: Multiplan Commercial |
$4,481.15
|
| Rate for Payer: Preferred Network Access Commercial |
$5,153.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,744.71
|
| Rate for Payer: Quartz Commercial |
$3,360.86
|
| Rate for Payer: WEA Trust Commercial |
$3,080.79
|
| Rate for Payer: WPS Commercial |
$4,148.84
|
|
|
PLATE 10 HL 1/3 COLLAR 121mm
|
Facility
|
OP
|
$5,386.00
|
|
| Hospital Charge Code |
2966317
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,568.40 |
| Max. Negotiated Rate |
$5,153.32 |
| Rate for Payer: Aetna Commercial |
$5,041.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,817.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,568.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,640.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,800.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,688.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,968.76
|
| Rate for Payer: Cash Price |
$1,615.80
|
| Rate for Payer: Cigna Commercial |
$5,153.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,134.65
|
| Rate for Payer: Health EOS Commercial |
$4,985.28
|
| Rate for Payer: HFN Commercial |
$5,153.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,201.08
|
| Rate for Payer: Multiplan Commercial |
$4,481.15
|
| Rate for Payer: NAPHCARE Commercial |
$3,360.86
|
| Rate for Payer: Preferred Network Access Commercial |
$5,153.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,744.71
|
| Rate for Payer: Quartz Commercial |
$3,640.94
|
| Rate for Payer: Quartz Medicare Advantage |
$3,360.86
|
| Rate for Payer: The Alliance Commercial |
$2,800.72
|
| Rate for Payer: WEA Trust Commercial |
$3,080.79
|
| Rate for Payer: WPS Commercial |
$4,148.84
|
|
|
PLATE 10H LT CONDYLAR 222.661
|
Facility
|
OP
|
$4,678.00
|
|
| Hospital Charge Code |
2966664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.23 |
| Max. Negotiated Rate |
$4,475.91 |
| Rate for Payer: Aetna Commercial |
$4,378.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,184.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,362.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,162.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,432.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,578.51
|
| Rate for Payer: Cash Price |
$1,403.40
|
| Rate for Payer: Cigna Commercial |
$4,475.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,722.60
|
| Rate for Payer: Health EOS Commercial |
$4,329.96
|
| Rate for Payer: HFN Commercial |
$4,475.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,648.84
|
| Rate for Payer: Multiplan Commercial |
$3,892.10
|
| Rate for Payer: NAPHCARE Commercial |
$2,919.07
|
| Rate for Payer: Preferred Network Access Commercial |
$4,475.91
|
| Rate for Payer: Quartz Beloit One Network |
$2,383.91
|
| Rate for Payer: Quartz Commercial |
$3,162.33
|
| Rate for Payer: Quartz Medicare Advantage |
$2,919.07
|
| Rate for Payer: The Alliance Commercial |
$2,432.56
|
| Rate for Payer: WEA Trust Commercial |
$2,675.82
|
| Rate for Payer: WPS Commercial |
$3,603.46
|
|
|
PLATE 10H LT CONDYLAR 222.661
|
Facility
|
IP
|
$4,678.00
|
|
| Hospital Charge Code |
2966664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,383.91 |
| Max. Negotiated Rate |
$4,475.91 |
| Rate for Payer: Aetna Commercial |
$4,378.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,184.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,578.51
|
| Rate for Payer: Cash Price |
$1,403.40
|
| Rate for Payer: Cigna Commercial |
$4,475.91
|
| Rate for Payer: Health EOS Commercial |
$4,329.96
|
| Rate for Payer: HFN Commercial |
$4,475.91
|
| Rate for Payer: Multiplan Commercial |
$3,892.10
|
| Rate for Payer: Preferred Network Access Commercial |
$4,475.91
|
| Rate for Payer: Quartz Beloit One Network |
$2,383.91
|
| Rate for Payer: Quartz Commercial |
$2,919.07
|
| Rate for Payer: WEA Trust Commercial |
$2,675.82
|
| Rate for Payer: WPS Commercial |
$3,603.46
|
|
|
PLATE 10H LT PROX/TIB 240.043
|
Facility
|
OP
|
$4,732.00
|
|
| Hospital Charge Code |
2966665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,377.96 |
| Max. Negotiated Rate |
$4,527.58 |
| Rate for Payer: Aetna Commercial |
$4,429.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,232.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,377.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,198.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,460.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,362.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,608.28
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,527.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,754.02
|
| Rate for Payer: Health EOS Commercial |
$4,379.94
|
| Rate for Payer: HFN Commercial |
$4,527.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,690.96
|
| Rate for Payer: Multiplan Commercial |
$3,937.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,952.77
|
| Rate for Payer: Preferred Network Access Commercial |
$4,527.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,411.43
|
| Rate for Payer: Quartz Commercial |
$3,198.83
|
| Rate for Payer: Quartz Medicare Advantage |
$2,952.77
|
| Rate for Payer: The Alliance Commercial |
$2,460.64
|
| Rate for Payer: WEA Trust Commercial |
$2,706.70
|
| Rate for Payer: WPS Commercial |
$3,645.06
|
|
|
PLATE 10H LT PROX/TIB 240.043
|
Facility
|
IP
|
$4,732.00
|
|
| Hospital Charge Code |
2966665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,411.43 |
| Max. Negotiated Rate |
$4,527.58 |
| Rate for Payer: Aetna Commercial |
$4,429.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,232.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,608.28
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,527.58
|
| Rate for Payer: Health EOS Commercial |
$4,379.94
|
| Rate for Payer: HFN Commercial |
$4,527.58
|
| Rate for Payer: Multiplan Commercial |
$3,937.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,527.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,411.43
|
| Rate for Payer: Quartz Commercial |
$2,952.77
|
| Rate for Payer: WEA Trust Commercial |
$2,706.70
|
| Rate for Payer: WPS Commercial |
$3,645.06
|
|
|
PLATE 10H RT CONDYLAR 222.660
|
Facility
|
OP
|
$4,678.00
|
|
| Hospital Charge Code |
2966666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.23 |
| Max. Negotiated Rate |
$4,475.91 |
| Rate for Payer: Aetna Commercial |
$4,378.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,184.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,362.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,162.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,432.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,578.51
|
| Rate for Payer: Cash Price |
$1,403.40
|
| Rate for Payer: Cigna Commercial |
$4,475.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,722.60
|
| Rate for Payer: Health EOS Commercial |
$4,329.96
|
| Rate for Payer: HFN Commercial |
$4,475.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,648.84
|
| Rate for Payer: Multiplan Commercial |
$3,892.10
|
| Rate for Payer: NAPHCARE Commercial |
$2,919.07
|
| Rate for Payer: Preferred Network Access Commercial |
$4,475.91
|
| Rate for Payer: Quartz Beloit One Network |
$2,383.91
|
| Rate for Payer: Quartz Commercial |
$3,162.33
|
| Rate for Payer: Quartz Medicare Advantage |
$2,919.07
|
| Rate for Payer: The Alliance Commercial |
$2,432.56
|
| Rate for Payer: WEA Trust Commercial |
$2,675.82
|
| Rate for Payer: WPS Commercial |
$3,603.46
|
|
|
PLATE 10H RT CONDYLAR 222.660
|
Facility
|
IP
|
$4,678.00
|
|
| Hospital Charge Code |
2966666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,383.91 |
| Max. Negotiated Rate |
$4,475.91 |
| Rate for Payer: Aetna Commercial |
$4,378.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,184.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,578.51
|
| Rate for Payer: Cash Price |
$1,403.40
|
| Rate for Payer: Cigna Commercial |
$4,475.91
|
| Rate for Payer: Health EOS Commercial |
$4,329.96
|
| Rate for Payer: HFN Commercial |
$4,475.91
|
| Rate for Payer: Multiplan Commercial |
$3,892.10
|
| Rate for Payer: Preferred Network Access Commercial |
$4,475.91
|
| Rate for Payer: Quartz Beloit One Network |
$2,383.91
|
| Rate for Payer: Quartz Commercial |
$2,919.07
|
| Rate for Payer: WEA Trust Commercial |
$2,675.82
|
| Rate for Payer: WPS Commercial |
$3,603.46
|
|
|
PLATE 10H RT PROX/TIB 240.042
|
Facility
|
OP
|
$4,732.00
|
|
| Hospital Charge Code |
2966667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,377.96 |
| Max. Negotiated Rate |
$4,527.58 |
| Rate for Payer: Aetna Commercial |
$4,429.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,232.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,377.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,198.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,460.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,362.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,608.28
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,527.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,754.02
|
| Rate for Payer: Health EOS Commercial |
$4,379.94
|
| Rate for Payer: HFN Commercial |
$4,527.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,690.96
|
| Rate for Payer: Multiplan Commercial |
$3,937.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,952.77
|
| Rate for Payer: Preferred Network Access Commercial |
$4,527.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,411.43
|
| Rate for Payer: Quartz Commercial |
$3,198.83
|
| Rate for Payer: Quartz Medicare Advantage |
$2,952.77
|
| Rate for Payer: The Alliance Commercial |
$2,460.64
|
| Rate for Payer: WEA Trust Commercial |
$2,706.70
|
| Rate for Payer: WPS Commercial |
$3,645.06
|
|
|
PLATE 10H RT PROX/TIB 240.042
|
Facility
|
IP
|
$4,732.00
|
|
| Hospital Charge Code |
2966667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,411.43 |
| Max. Negotiated Rate |
$4,527.58 |
| Rate for Payer: Aetna Commercial |
$4,429.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,232.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,608.28
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,527.58
|
| Rate for Payer: Health EOS Commercial |
$4,379.94
|
| Rate for Payer: HFN Commercial |
$4,527.58
|
| Rate for Payer: Multiplan Commercial |
$3,937.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,527.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,411.43
|
| Rate for Payer: Quartz Commercial |
$2,952.77
|
| Rate for Payer: WEA Trust Commercial |
$2,706.70
|
| Rate for Payer: WPS Commercial |
$3,645.06
|
|
|
PLATE 12H 3.5 LCP 223.621
|
Facility
|
IP
|
$1,732.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$882.63 |
| Max. Negotiated Rate |
$1,657.18 |
| Rate for Payer: Aetna Commercial |
$1,621.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,549.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.68
|
| Rate for Payer: Cash Price |
$519.60
|
| Rate for Payer: Cigna Commercial |
$1,657.18
|
| Rate for Payer: Health EOS Commercial |
$1,603.14
|
| Rate for Payer: HFN Commercial |
$1,657.18
|
| Rate for Payer: Multiplan Commercial |
$1,441.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,657.18
|
| Rate for Payer: Quartz Beloit One Network |
$882.63
|
| Rate for Payer: Quartz Commercial |
$1,080.77
|
| Rate for Payer: WEA Trust Commercial |
$990.70
|
| Rate for Payer: WPS Commercial |
$1,334.16
|
|
|
PLATE 12H 3.5 LCP 223.621
|
Facility
|
OP
|
$1,732.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$504.36 |
| Max. Negotiated Rate |
$1,657.18 |
| Rate for Payer: Aetna Commercial |
$1,621.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,549.10
|
| Rate for Payer: Aetna Managed Medicare |
$504.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,170.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$900.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$864.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.68
|
| Rate for Payer: Cash Price |
$519.60
|
| Rate for Payer: Cigna Commercial |
$1,657.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,008.02
|
| Rate for Payer: Health EOS Commercial |
$1,603.14
|
| Rate for Payer: HFN Commercial |
$1,657.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,350.96
|
| Rate for Payer: Multiplan Commercial |
$1,441.02
|
| Rate for Payer: NAPHCARE Commercial |
$1,080.77
|
| Rate for Payer: Preferred Network Access Commercial |
$1,657.18
|
| Rate for Payer: Quartz Beloit One Network |
$882.63
|
| Rate for Payer: Quartz Commercial |
$1,170.83
|
| Rate for Payer: Quartz Medicare Advantage |
$1,080.77
|
| Rate for Payer: The Alliance Commercial |
$900.64
|
| Rate for Payer: WEA Trust Commercial |
$990.70
|
| Rate for Payer: WPS Commercial |
$1,334.16
|
|
|
PLATE 12H 3.5 LCP RECO 245.121
|
Facility
|
OP
|
$2,641.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$769.06 |
| Max. Negotiated Rate |
$2,526.91 |
| Rate for Payer: Aetna Commercial |
$2,471.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,362.11
|
| Rate for Payer: Aetna Managed Medicare |
$769.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,785.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,373.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,318.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,455.72
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,526.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,537.06
|
| Rate for Payer: Health EOS Commercial |
$2,444.51
|
| Rate for Payer: HFN Commercial |
$2,526.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,059.98
|
| Rate for Payer: Multiplan Commercial |
$2,197.31
|
| Rate for Payer: NAPHCARE Commercial |
$1,647.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,526.91
|
| Rate for Payer: Quartz Beloit One Network |
$1,345.85
|
| Rate for Payer: Quartz Commercial |
$1,785.32
|
| Rate for Payer: Quartz Medicare Advantage |
$1,647.98
|
| Rate for Payer: The Alliance Commercial |
$1,373.32
|
| Rate for Payer: WEA Trust Commercial |
$1,510.65
|
| Rate for Payer: WPS Commercial |
$2,034.36
|
|
|
PLATE 12H 3.5 LCP RECO 245.121
|
Facility
|
IP
|
$2,641.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,345.85 |
| Max. Negotiated Rate |
$2,526.91 |
| Rate for Payer: Aetna Commercial |
$2,471.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,362.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,455.72
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,526.91
|
| Rate for Payer: Health EOS Commercial |
$2,444.51
|
| Rate for Payer: HFN Commercial |
$2,526.91
|
| Rate for Payer: Multiplan Commercial |
$2,197.31
|
| Rate for Payer: Preferred Network Access Commercial |
$2,526.91
|
| Rate for Payer: Quartz Beloit One Network |
$1,345.85
|
| Rate for Payer: Quartz Commercial |
$1,647.98
|
| Rate for Payer: WEA Trust Commercial |
$1,510.65
|
| Rate for Payer: WPS Commercial |
$2,034.36
|
|
|
PLATE 12H LT CONDYLAR 222.663
|
Facility
|
IP
|
$4,449.00
|
|
| Hospital Charge Code |
2966671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,267.21 |
| Max. Negotiated Rate |
$4,256.80 |
| Rate for Payer: Aetna Commercial |
$4,164.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,979.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,452.29
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,256.80
|
| Rate for Payer: Health EOS Commercial |
$4,117.99
|
| Rate for Payer: HFN Commercial |
$4,256.80
|
| Rate for Payer: Multiplan Commercial |
$3,701.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,256.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,267.21
|
| Rate for Payer: Quartz Commercial |
$2,776.18
|
| Rate for Payer: WEA Trust Commercial |
$2,544.83
|
| Rate for Payer: WPS Commercial |
$3,427.06
|
|
|
PLATE 12H LT CONDYLAR 222.663
|
Facility
|
OP
|
$4,449.00
|
|
| Hospital Charge Code |
2966671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,295.55 |
| Max. Negotiated Rate |
$4,256.80 |
| Rate for Payer: Aetna Commercial |
$4,164.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,979.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,295.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,007.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,313.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,220.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,452.29
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,256.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,589.32
|
| Rate for Payer: Health EOS Commercial |
$4,117.99
|
| Rate for Payer: HFN Commercial |
$4,256.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,470.22
|
| Rate for Payer: Multiplan Commercial |
$3,701.57
|
| Rate for Payer: NAPHCARE Commercial |
$2,776.18
|
| Rate for Payer: Preferred Network Access Commercial |
$4,256.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,267.21
|
| Rate for Payer: Quartz Commercial |
$3,007.52
|
| Rate for Payer: Quartz Medicare Advantage |
$2,776.18
|
| Rate for Payer: The Alliance Commercial |
$2,313.48
|
| Rate for Payer: WEA Trust Commercial |
$2,544.83
|
| Rate for Payer: WPS Commercial |
$3,427.06
|
|
|
PLATE 12H LT PROX/TIB 240.045
|
Facility
|
OP
|
$4,787.00
|
|
| Hospital Charge Code |
2966672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.97 |
| Max. Negotiated Rate |
$4,580.20 |
| Rate for Payer: Aetna Commercial |
$4,480.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.49
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,236.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.59
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,580.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,786.03
|
| Rate for Payer: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.86
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,987.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.46
|
| Rate for Payer: Quartz Commercial |
$3,236.01
|
| Rate for Payer: Quartz Medicare Advantage |
$2,987.09
|
| Rate for Payer: The Alliance Commercial |
$2,489.24
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
