|
PLATE 12H LT PROX/TIB 240.045
|
Facility
|
IP
|
$4,787.00
|
|
| Hospital Charge Code |
2966672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.46 |
| 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: 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: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| 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 |
$2,987.09
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
|
PLATE 12 HOLE CURVED BROAD
|
Facility
|
OP
|
$6,880.00
|
|
| Hospital Charge Code |
2966318
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,003.46 |
| Max. Negotiated Rate |
$6,582.78 |
| Rate for Payer: Aetna Commercial |
$6,439.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,153.47
|
| Rate for Payer: Aetna Managed Medicare |
$2,003.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,650.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,577.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,434.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,792.26
|
| Rate for Payer: Cash Price |
$2,064.00
|
| Rate for Payer: Cigna Commercial |
$6,582.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,004.16
|
| Rate for Payer: Health EOS Commercial |
$6,368.13
|
| Rate for Payer: HFN Commercial |
$6,582.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,366.40
|
| Rate for Payer: Multiplan Commercial |
$5,724.16
|
| Rate for Payer: NAPHCARE Commercial |
$4,293.12
|
| Rate for Payer: Preferred Network Access Commercial |
$6,582.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,506.05
|
| Rate for Payer: Quartz Commercial |
$4,650.88
|
| Rate for Payer: Quartz Medicare Advantage |
$4,293.12
|
| Rate for Payer: The Alliance Commercial |
$3,577.60
|
| Rate for Payer: WEA Trust Commercial |
$3,935.36
|
| Rate for Payer: WPS Commercial |
$5,299.66
|
|
|
PLATE 12 HOLE CURVED BROAD
|
Facility
|
IP
|
$6,880.00
|
|
| Hospital Charge Code |
2966318
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,506.05 |
| Max. Negotiated Rate |
$6,582.78 |
| Rate for Payer: Aetna Commercial |
$6,439.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,153.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,792.26
|
| Rate for Payer: Cash Price |
$2,064.00
|
| Rate for Payer: Cigna Commercial |
$6,582.78
|
| Rate for Payer: Health EOS Commercial |
$6,368.13
|
| Rate for Payer: HFN Commercial |
$6,582.78
|
| Rate for Payer: Multiplan Commercial |
$5,724.16
|
| Rate for Payer: Preferred Network Access Commercial |
$6,582.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,506.05
|
| Rate for Payer: Quartz Commercial |
$4,293.12
|
| Rate for Payer: WEA Trust Commercial |
$3,935.36
|
| Rate for Payer: WPS Commercial |
$5,299.66
|
|
|
PLATE 12H RT CONDYLAR 02.001.322
|
Facility
|
IP
|
$4,449.00
|
|
| Hospital Charge Code |
2966670
|
|
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 RT CONDYLAR 02.001.322
|
Facility
|
OP
|
$4,449.00
|
|
| Hospital Charge Code |
2966670
|
|
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 RT PROX/TIB 240.044
|
Facility
|
IP
|
$4,787.00
|
|
| Hospital Charge Code |
2966673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.46 |
| 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: 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: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| 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 |
$2,987.09
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
|
PLATE 12H RT PROX/TIB 240.044
|
Facility
|
OP
|
$4,787.00
|
|
| Hospital Charge Code |
2966673
|
|
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
|
|
|
PLATE 1/3 TUB 10HL 241.401
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966643
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$403.60 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$494.21
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
PLATE 1/3 TUB 10HL 241.401
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966643
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.63 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Aetna Managed Medicare |
$230.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$535.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$411.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$395.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$460.94
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$617.76
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: NAPHCARE Commercial |
$494.21
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$535.39
|
| Rate for Payer: Quartz Medicare Advantage |
$494.21
|
| Rate for Payer: The Alliance Commercial |
$411.84
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
PLATE 1/3 TUB 10HL STRYKER 626680
|
Facility
|
IP
|
$3,646.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,858.00 |
| Max. Negotiated Rate |
$3,488.49 |
| Rate for Payer: Aetna Commercial |
$3,412.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,260.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,009.68
|
| Rate for Payer: Cash Price |
$1,093.80
|
| Rate for Payer: Cigna Commercial |
$3,488.49
|
| Rate for Payer: Health EOS Commercial |
$3,374.74
|
| Rate for Payer: HFN Commercial |
$3,488.49
|
| Rate for Payer: Multiplan Commercial |
$3,033.47
|
| Rate for Payer: Preferred Network Access Commercial |
$3,488.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,858.00
|
| Rate for Payer: Quartz Commercial |
$2,275.10
|
| Rate for Payer: WEA Trust Commercial |
$2,085.51
|
| Rate for Payer: WPS Commercial |
$2,808.51
|
|
|
PLATE 1/3 TUB 10HL STRYKER 626680
|
Facility
|
OP
|
$3,646.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,061.72 |
| Max. Negotiated Rate |
$3,488.49 |
| Rate for Payer: Aetna Commercial |
$3,412.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,260.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,061.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,464.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,895.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,820.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,009.68
|
| Rate for Payer: Cash Price |
$1,093.80
|
| Rate for Payer: Cigna Commercial |
$3,488.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,121.97
|
| Rate for Payer: Health EOS Commercial |
$3,374.74
|
| Rate for Payer: HFN Commercial |
$3,488.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,843.88
|
| Rate for Payer: Multiplan Commercial |
$3,033.47
|
| Rate for Payer: NAPHCARE Commercial |
$2,275.10
|
| Rate for Payer: Preferred Network Access Commercial |
$3,488.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,858.00
|
| Rate for Payer: Quartz Commercial |
$2,464.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,275.10
|
| Rate for Payer: The Alliance Commercial |
$1,895.92
|
| Rate for Payer: WEA Trust Commercial |
$2,085.51
|
| Rate for Payer: WPS Commercial |
$2,808.51
|
|
|
PLATE 1/3 TUB 12HL 241.421
|
Facility
|
OP
|
$822.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$239.37 |
| Max. Negotiated Rate |
$786.49 |
| Rate for Payer: Aetna Commercial |
$769.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.20
|
| Rate for Payer: Aetna Managed Medicare |
$239.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$555.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$427.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$410.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.09
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$786.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$478.40
|
| Rate for Payer: Health EOS Commercial |
$760.84
|
| Rate for Payer: HFN Commercial |
$786.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$641.16
|
| Rate for Payer: Multiplan Commercial |
$683.90
|
| Rate for Payer: NAPHCARE Commercial |
$512.93
|
| Rate for Payer: Preferred Network Access Commercial |
$786.49
|
| Rate for Payer: Quartz Beloit One Network |
$418.89
|
| Rate for Payer: Quartz Commercial |
$555.67
|
| Rate for Payer: Quartz Medicare Advantage |
$512.93
|
| Rate for Payer: The Alliance Commercial |
$427.44
|
| Rate for Payer: WEA Trust Commercial |
$470.18
|
| Rate for Payer: WPS Commercial |
$633.19
|
|
|
PLATE 1/3 TUB 12HL 241.421
|
Facility
|
IP
|
$822.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.89 |
| Max. Negotiated Rate |
$786.49 |
| Rate for Payer: Aetna Commercial |
$769.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.09
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$786.49
|
| Rate for Payer: Health EOS Commercial |
$760.84
|
| Rate for Payer: HFN Commercial |
$786.49
|
| Rate for Payer: Multiplan Commercial |
$683.90
|
| Rate for Payer: Preferred Network Access Commercial |
$786.49
|
| Rate for Payer: Quartz Beloit One Network |
$418.89
|
| Rate for Payer: Quartz Commercial |
$512.93
|
| Rate for Payer: WEA Trust Commercial |
$470.18
|
| Rate for Payer: WPS Commercial |
$633.19
|
|
|
PLATE 1/3 TUB 5HL 241.351
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.61 |
| Max. Negotiated Rate |
$705.16 |
| Rate for Payer: Aetna Commercial |
$689.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$659.17
|
| Rate for Payer: Aetna Managed Medicare |
$214.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$498.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$383.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$367.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$406.23
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$705.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$428.93
|
| Rate for Payer: Health EOS Commercial |
$682.17
|
| Rate for Payer: HFN Commercial |
$705.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.86
|
| Rate for Payer: Multiplan Commercial |
$613.18
|
| Rate for Payer: NAPHCARE Commercial |
$459.89
|
| Rate for Payer: Preferred Network Access Commercial |
$705.16
|
| Rate for Payer: Quartz Beloit One Network |
$375.58
|
| Rate for Payer: Quartz Commercial |
$498.21
|
| Rate for Payer: Quartz Medicare Advantage |
$459.89
|
| Rate for Payer: The Alliance Commercial |
$383.24
|
| Rate for Payer: WEA Trust Commercial |
$421.56
|
| Rate for Payer: WPS Commercial |
$567.71
|
|
|
PLATE 1/3 TUB 5HL 241.351
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$375.58 |
| Max. Negotiated Rate |
$705.16 |
| Rate for Payer: Aetna Commercial |
$689.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$659.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$406.23
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$705.16
|
| Rate for Payer: Health EOS Commercial |
$682.17
|
| Rate for Payer: HFN Commercial |
$705.16
|
| Rate for Payer: Multiplan Commercial |
$613.18
|
| Rate for Payer: Preferred Network Access Commercial |
$705.16
|
| Rate for Payer: Quartz Beloit One Network |
$375.58
|
| Rate for Payer: Quartz Commercial |
$459.89
|
| Rate for Payer: WEA Trust Commercial |
$421.56
|
| Rate for Payer: WPS Commercial |
$567.71
|
|
|
PLATE 1/3 TUB 6HL 241.361
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$375.58 |
| Max. Negotiated Rate |
$705.16 |
| Rate for Payer: Aetna Commercial |
$689.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$659.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$406.23
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$705.16
|
| Rate for Payer: Health EOS Commercial |
$682.17
|
| Rate for Payer: HFN Commercial |
$705.16
|
| Rate for Payer: Multiplan Commercial |
$613.18
|
| Rate for Payer: Preferred Network Access Commercial |
$705.16
|
| Rate for Payer: Quartz Beloit One Network |
$375.58
|
| Rate for Payer: Quartz Commercial |
$459.89
|
| Rate for Payer: WEA Trust Commercial |
$421.56
|
| Rate for Payer: WPS Commercial |
$567.71
|
|
|
PLATE 1/3 TUB 6HL 241.361
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.61 |
| Max. Negotiated Rate |
$705.16 |
| Rate for Payer: Aetna Commercial |
$689.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$659.17
|
| Rate for Payer: Aetna Managed Medicare |
$214.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$498.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$383.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$367.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$406.23
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$705.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$428.93
|
| Rate for Payer: Health EOS Commercial |
$682.17
|
| Rate for Payer: HFN Commercial |
$705.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.86
|
| Rate for Payer: Multiplan Commercial |
$613.18
|
| Rate for Payer: NAPHCARE Commercial |
$459.89
|
| Rate for Payer: Preferred Network Access Commercial |
$705.16
|
| Rate for Payer: Quartz Beloit One Network |
$375.58
|
| Rate for Payer: Quartz Commercial |
$498.21
|
| Rate for Payer: Quartz Medicare Advantage |
$459.89
|
| Rate for Payer: The Alliance Commercial |
$383.24
|
| Rate for Payer: WEA Trust Commercial |
$421.56
|
| Rate for Payer: WPS Commercial |
$567.71
|
|
|
PLATE 1/3 TUB 7HL 241.371
|
Facility
|
OP
|
$757.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966653
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$220.44 |
| Max. Negotiated Rate |
$724.30 |
| Rate for Payer: Aetna Commercial |
$708.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$677.06
|
| Rate for Payer: Aetna Managed Medicare |
$220.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$511.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$393.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$377.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.26
|
| Rate for Payer: Cash Price |
$227.10
|
| Rate for Payer: Cigna Commercial |
$724.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$440.57
|
| Rate for Payer: Health EOS Commercial |
$700.68
|
| Rate for Payer: HFN Commercial |
$724.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$590.46
|
| Rate for Payer: Multiplan Commercial |
$629.82
|
| Rate for Payer: NAPHCARE Commercial |
$472.37
|
| Rate for Payer: Preferred Network Access Commercial |
$724.30
|
| Rate for Payer: Quartz Beloit One Network |
$385.77
|
| Rate for Payer: Quartz Commercial |
$511.73
|
| Rate for Payer: Quartz Medicare Advantage |
$472.37
|
| Rate for Payer: The Alliance Commercial |
$393.64
|
| Rate for Payer: WEA Trust Commercial |
$433.00
|
| Rate for Payer: WPS Commercial |
$583.12
|
|
|
PLATE 1/3 TUB 7HL 241.371
|
Facility
|
IP
|
$757.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966653
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$385.77 |
| Max. Negotiated Rate |
$724.30 |
| Rate for Payer: Aetna Commercial |
$708.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$677.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.26
|
| Rate for Payer: Cash Price |
$227.10
|
| Rate for Payer: Cigna Commercial |
$724.30
|
| Rate for Payer: Health EOS Commercial |
$700.68
|
| Rate for Payer: HFN Commercial |
$724.30
|
| Rate for Payer: Multiplan Commercial |
$629.82
|
| Rate for Payer: Preferred Network Access Commercial |
$724.30
|
| Rate for Payer: Quartz Beloit One Network |
$385.77
|
| Rate for Payer: Quartz Commercial |
$472.37
|
| Rate for Payer: WEA Trust Commercial |
$433.00
|
| Rate for Payer: WPS Commercial |
$583.12
|
|
|
PLATE 1/3 TUB 8HL 241.381
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.63 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Aetna Managed Medicare |
$230.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$535.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$411.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$395.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$460.94
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$617.76
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: NAPHCARE Commercial |
$494.21
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$535.39
|
| Rate for Payer: Quartz Medicare Advantage |
$494.21
|
| Rate for Payer: The Alliance Commercial |
$411.84
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
PLATE 1/3 TUB 8HL 241.381
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$403.60 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$494.21
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
PLATE 1/3 TUBUALR LOCK 10HL ARTHREX AR-8943T-10
|
Facility
|
OP
|
$2,979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$867.48 |
| Max. Negotiated Rate |
$2,850.31 |
| Rate for Payer: Aetna Commercial |
$2,788.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,664.42
|
| Rate for Payer: Aetna Managed Medicare |
$867.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,013.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,549.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,487.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,642.02
|
| Rate for Payer: Cash Price |
$893.70
|
| Rate for Payer: Cigna Commercial |
$2,850.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,733.78
|
| Rate for Payer: Health EOS Commercial |
$2,757.36
|
| Rate for Payer: HFN Commercial |
$2,850.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,323.62
|
| Rate for Payer: Multiplan Commercial |
$2,478.53
|
| Rate for Payer: NAPHCARE Commercial |
$1,858.90
|
| Rate for Payer: Preferred Network Access Commercial |
$2,850.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,518.10
|
| Rate for Payer: Quartz Commercial |
$2,013.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,858.90
|
| Rate for Payer: The Alliance Commercial |
$1,549.08
|
| Rate for Payer: WEA Trust Commercial |
$1,703.99
|
| Rate for Payer: WPS Commercial |
$2,294.72
|
|
|
PLATE 1/3 TUBUALR LOCK 10HL ARTHREX AR-8943T-10
|
Facility
|
IP
|
$2,979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,518.10 |
| Max. Negotiated Rate |
$2,850.31 |
| Rate for Payer: Aetna Commercial |
$2,788.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,664.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,642.02
|
| Rate for Payer: Cash Price |
$893.70
|
| Rate for Payer: Cigna Commercial |
$2,850.31
|
| Rate for Payer: Health EOS Commercial |
$2,757.36
|
| Rate for Payer: HFN Commercial |
$2,850.31
|
| Rate for Payer: Multiplan Commercial |
$2,478.53
|
| Rate for Payer: Preferred Network Access Commercial |
$2,850.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,518.10
|
| Rate for Payer: Quartz Commercial |
$1,858.90
|
| Rate for Payer: WEA Trust Commercial |
$1,703.99
|
| Rate for Payer: WPS Commercial |
$2,294.72
|
|
|
PLATE 1/3 TUBUALR LOCK 12HL ARTHREX AR-8943T-12
|
Facility
|
OP
|
$3,848.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6178526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.54 |
| Max. Negotiated Rate |
$3,681.77 |
| Rate for Payer: Aetna Commercial |
$3,601.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,120.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,601.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,000.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,920.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,121.02
|
| Rate for Payer: Cash Price |
$1,154.40
|
| Rate for Payer: Cigna Commercial |
$3,681.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,239.54
|
| Rate for Payer: Health EOS Commercial |
$3,561.71
|
| Rate for Payer: HFN Commercial |
$3,681.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,001.44
|
| Rate for Payer: Multiplan Commercial |
$3,201.54
|
| Rate for Payer: NAPHCARE Commercial |
$2,401.15
|
| Rate for Payer: Preferred Network Access Commercial |
$3,681.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,960.94
|
| Rate for Payer: Quartz Commercial |
$2,601.25
|
| Rate for Payer: Quartz Medicare Advantage |
$2,401.15
|
| Rate for Payer: The Alliance Commercial |
$2,000.96
|
| Rate for Payer: WEA Trust Commercial |
$2,201.06
|
| Rate for Payer: WPS Commercial |
$2,964.11
|
|
|
PLATE 1/3 TUBUALR LOCK 12HL ARTHREX AR-8943T-12
|
Facility
|
IP
|
$3,848.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6178526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,960.94 |
| Max. Negotiated Rate |
$3,681.77 |
| Rate for Payer: Aetna Commercial |
$3,601.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,441.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,121.02
|
| Rate for Payer: Cash Price |
$1,154.40
|
| Rate for Payer: Cigna Commercial |
$3,681.77
|
| Rate for Payer: Health EOS Commercial |
$3,561.71
|
| Rate for Payer: HFN Commercial |
$3,681.77
|
| Rate for Payer: Multiplan Commercial |
$3,201.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,681.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,960.94
|
| Rate for Payer: Quartz Commercial |
$2,401.15
|
| Rate for Payer: WEA Trust Commercial |
$2,201.06
|
| Rate for Payer: WPS Commercial |
$2,964.11
|
|
