|
PLATE 10H RT PROX/TIB 240.042
|
Facility
|
IP
|
$4,732.00
|
|
| Hospital Charge Code |
2966667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,318.68 |
| Max. Negotiated Rate |
$4,353.44 |
| Rate for Payer: Aetna Commercial |
$4,258.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,069.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,507.96
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,353.44
|
| Rate for Payer: Health EOS Commercial |
$4,211.48
|
| Rate for Payer: HFN Commercial |
$4,353.44
|
| Rate for Payer: Multiplan Commercial |
$3,785.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,839.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,353.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,318.68
|
| Rate for Payer: Quartz Commercial |
$2,839.20
|
| Rate for Payer: WEA Trust Commercial |
$2,602.60
|
| Rate for Payer: WPS Commercial |
$3,504.99
|
|
|
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 |
$484.96 |
| Max. Negotiated Rate |
$6,928.00 |
| Rate for Payer: Aetna Commercial |
$1,558.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,489.52
|
| Rate for Payer: Aetna Managed Medicare |
$484.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,125.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$866.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$831.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$917.96
|
| Rate for Payer: Cash Price |
$519.60
|
| Rate for Payer: Cigna Commercial |
$1,593.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$969.23
|
| Rate for Payer: Health EOS Commercial |
$1,541.48
|
| Rate for Payer: HFN Commercial |
$1,593.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,299.00
|
| Rate for Payer: Multiplan Commercial |
$1,385.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,039.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,593.44
|
| Rate for Payer: Quartz Beloit One Network |
$848.68
|
| Rate for Payer: Quartz Commercial |
$1,125.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,039.20
|
| Rate for Payer: The Alliance Commercial |
$6,928.00
|
| Rate for Payer: WEA Trust Commercial |
$952.60
|
| Rate for Payer: WPS Commercial |
$1,282.89
|
|
|
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 |
$848.68 |
| Max. Negotiated Rate |
$1,593.44 |
| Rate for Payer: Aetna Commercial |
$1,558.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,489.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$917.96
|
| Rate for Payer: Cash Price |
$519.60
|
| Rate for Payer: Cigna Commercial |
$1,593.44
|
| Rate for Payer: Health EOS Commercial |
$1,541.48
|
| Rate for Payer: HFN Commercial |
$1,593.44
|
| Rate for Payer: Multiplan Commercial |
$1,385.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,039.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,593.44
|
| Rate for Payer: Quartz Beloit One Network |
$848.68
|
| Rate for Payer: Quartz Commercial |
$1,039.20
|
| Rate for Payer: WEA Trust Commercial |
$952.60
|
| Rate for Payer: WPS Commercial |
$1,282.89
|
|
|
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 |
$739.48 |
| Max. Negotiated Rate |
$10,564.00 |
| Rate for Payer: Aetna Commercial |
$2,376.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,271.26
|
| Rate for Payer: Aetna Managed Medicare |
$739.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,716.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,320.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,267.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,399.73
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,429.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,477.90
|
| Rate for Payer: Health EOS Commercial |
$2,350.49
|
| Rate for Payer: HFN Commercial |
$2,429.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,980.75
|
| Rate for Payer: Multiplan Commercial |
$2,112.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,584.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,429.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,294.09
|
| Rate for Payer: Quartz Commercial |
$1,716.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,584.60
|
| Rate for Payer: The Alliance Commercial |
$10,564.00
|
| Rate for Payer: WEA Trust Commercial |
$1,452.55
|
| Rate for Payer: WPS Commercial |
$1,956.19
|
|
|
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 |
$1,294.09 |
| Max. Negotiated Rate |
$2,429.72 |
| Rate for Payer: Aetna Commercial |
$2,376.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,271.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,399.73
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,429.72
|
| Rate for Payer: Health EOS Commercial |
$2,350.49
|
| Rate for Payer: HFN Commercial |
$2,429.72
|
| Rate for Payer: Multiplan Commercial |
$2,112.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,584.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,429.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,294.09
|
| Rate for Payer: Quartz Commercial |
$1,584.60
|
| Rate for Payer: WEA Trust Commercial |
$1,452.55
|
| Rate for Payer: WPS Commercial |
$1,956.19
|
|
|
PLATE 12H LT CONDYLAR 222.663
|
Facility
|
IP
|
$4,449.00
|
|
| Hospital Charge Code |
2966671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,180.01 |
| Max. Negotiated Rate |
$4,093.08 |
| Rate for Payer: Aetna Commercial |
$4,004.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,826.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,357.97
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,093.08
|
| Rate for Payer: Health EOS Commercial |
$3,959.61
|
| Rate for Payer: HFN Commercial |
$4,093.08
|
| Rate for Payer: Multiplan Commercial |
$3,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,669.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,093.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,180.01
|
| Rate for Payer: Quartz Commercial |
$2,669.40
|
| Rate for Payer: WEA Trust Commercial |
$2,446.95
|
| Rate for Payer: WPS Commercial |
$3,295.37
|
|
|
PLATE 12H LT CONDYLAR 222.663
|
Facility
|
OP
|
$4,449.00
|
|
| Hospital Charge Code |
2966671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,245.72 |
| Max. Negotiated Rate |
$17,796.00 |
| Rate for Payer: Aetna Commercial |
$4,004.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,826.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,245.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,891.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,224.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,135.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,357.97
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,093.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,489.66
|
| Rate for Payer: Health EOS Commercial |
$3,959.61
|
| Rate for Payer: HFN Commercial |
$4,093.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,336.75
|
| Rate for Payer: Multiplan Commercial |
$3,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,669.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,093.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,180.01
|
| Rate for Payer: Quartz Commercial |
$2,891.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,669.40
|
| Rate for Payer: The Alliance Commercial |
$17,796.00
|
| Rate for Payer: WEA Trust Commercial |
$2,446.95
|
| Rate for Payer: WPS Commercial |
$3,295.37
|
|
|
PLATE 12H LT PROX/TIB 240.045
|
Facility
|
OP
|
$4,787.00
|
|
| Hospital Charge Code |
2966672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,340.36 |
| Max. Negotiated Rate |
$19,148.00 |
| Rate for Payer: Aetna Commercial |
$4,308.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,116.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,340.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,111.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,393.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,297.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,537.11
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,404.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,678.81
|
| Rate for Payer: Health EOS Commercial |
$4,260.43
|
| Rate for Payer: HFN Commercial |
$4,404.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,590.25
|
| Rate for Payer: Multiplan Commercial |
$3,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,404.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,345.63
|
| Rate for Payer: Quartz Commercial |
$3,111.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,872.20
|
| Rate for Payer: The Alliance Commercial |
$19,148.00
|
| Rate for Payer: WEA Trust Commercial |
$2,632.85
|
| Rate for Payer: WPS Commercial |
$3,545.73
|
|
|
PLATE 12H LT PROX/TIB 240.045
|
Facility
|
IP
|
$4,787.00
|
|
| Hospital Charge Code |
2966672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,345.63 |
| Max. Negotiated Rate |
$4,404.04 |
| Rate for Payer: Aetna Commercial |
$4,308.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,116.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,537.11
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,404.04
|
| Rate for Payer: Health EOS Commercial |
$4,260.43
|
| Rate for Payer: HFN Commercial |
$4,404.04
|
| Rate for Payer: Multiplan Commercial |
$3,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,404.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,345.63
|
| Rate for Payer: Quartz Commercial |
$2,872.20
|
| Rate for Payer: WEA Trust Commercial |
$2,632.85
|
| Rate for Payer: WPS Commercial |
$3,545.73
|
|
|
PLATE 12 HOLE CURVED BROAD
|
Facility
|
OP
|
$6,880.00
|
|
| Hospital Charge Code |
2966318
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$27,520.00 |
| Rate for Payer: Aetna Commercial |
$6,192.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,916.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,926.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,472.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,440.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,302.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,646.40
|
| Rate for Payer: Cash Price |
$2,064.00
|
| Rate for Payer: Cigna Commercial |
$6,329.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,850.05
|
| Rate for Payer: Health EOS Commercial |
$6,123.20
|
| Rate for Payer: HFN Commercial |
$6,329.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,160.00
|
| Rate for Payer: Multiplan Commercial |
$5,504.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,329.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,371.20
|
| Rate for Payer: Quartz Commercial |
$4,472.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,128.00
|
| Rate for Payer: The Alliance Commercial |
$27,520.00
|
| Rate for Payer: WEA Trust Commercial |
$3,784.00
|
| Rate for Payer: WPS Commercial |
$5,096.02
|
|
|
PLATE 12 HOLE CURVED BROAD
|
Facility
|
IP
|
$6,880.00
|
|
| Hospital Charge Code |
2966318
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,371.20 |
| Max. Negotiated Rate |
$6,329.60 |
| Rate for Payer: Aetna Commercial |
$6,192.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,646.40
|
| Rate for Payer: Cash Price |
$2,064.00
|
| Rate for Payer: Cigna Commercial |
$6,329.60
|
| Rate for Payer: Health EOS Commercial |
$6,123.20
|
| Rate for Payer: HFN Commercial |
$6,329.60
|
| Rate for Payer: Multiplan Commercial |
$5,504.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,329.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,371.20
|
| Rate for Payer: Quartz Commercial |
$4,128.00
|
| Rate for Payer: WEA Trust Commercial |
$3,784.00
|
| Rate for Payer: WPS Commercial |
$5,096.02
|
|
|
PLATE 12H RT CONDYLAR 02.001.322
|
Facility
|
OP
|
$4,449.00
|
|
| Hospital Charge Code |
2966670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,245.72 |
| Max. Negotiated Rate |
$17,796.00 |
| Rate for Payer: Aetna Commercial |
$4,004.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,826.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,245.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,891.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,224.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,135.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,357.97
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,093.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,489.66
|
| Rate for Payer: Health EOS Commercial |
$3,959.61
|
| Rate for Payer: HFN Commercial |
$4,093.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,336.75
|
| Rate for Payer: Multiplan Commercial |
$3,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,669.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,093.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,180.01
|
| Rate for Payer: Quartz Commercial |
$2,891.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,669.40
|
| Rate for Payer: The Alliance Commercial |
$17,796.00
|
| Rate for Payer: WEA Trust Commercial |
$2,446.95
|
| Rate for Payer: WPS Commercial |
$3,295.37
|
|
|
PLATE 12H RT CONDYLAR 02.001.322
|
Facility
|
IP
|
$4,449.00
|
|
| Hospital Charge Code |
2966670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,180.01 |
| Max. Negotiated Rate |
$4,093.08 |
| Rate for Payer: Aetna Commercial |
$4,004.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,826.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,357.97
|
| Rate for Payer: Cash Price |
$1,334.70
|
| Rate for Payer: Cigna Commercial |
$4,093.08
|
| Rate for Payer: Health EOS Commercial |
$3,959.61
|
| Rate for Payer: HFN Commercial |
$4,093.08
|
| Rate for Payer: Multiplan Commercial |
$3,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,669.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,093.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,180.01
|
| Rate for Payer: Quartz Commercial |
$2,669.40
|
| Rate for Payer: WEA Trust Commercial |
$2,446.95
|
| Rate for Payer: WPS Commercial |
$3,295.37
|
|
|
PLATE 12H RT PROX/TIB 240.044
|
Facility
|
OP
|
$4,787.00
|
|
| Hospital Charge Code |
2966673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,340.36 |
| Max. Negotiated Rate |
$19,148.00 |
| Rate for Payer: Aetna Commercial |
$4,308.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,116.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,340.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,111.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,393.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,297.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,537.11
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,404.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,678.81
|
| Rate for Payer: Health EOS Commercial |
$4,260.43
|
| Rate for Payer: HFN Commercial |
$4,404.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,590.25
|
| Rate for Payer: Multiplan Commercial |
$3,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,404.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,345.63
|
| Rate for Payer: Quartz Commercial |
$3,111.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,872.20
|
| Rate for Payer: The Alliance Commercial |
$19,148.00
|
| Rate for Payer: WEA Trust Commercial |
$2,632.85
|
| Rate for Payer: WPS Commercial |
$3,545.73
|
|
|
PLATE 12H RT PROX/TIB 240.044
|
Facility
|
IP
|
$4,787.00
|
|
| Hospital Charge Code |
2966673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,345.63 |
| Max. Negotiated Rate |
$4,404.04 |
| Rate for Payer: Aetna Commercial |
$4,308.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,116.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,537.11
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,404.04
|
| Rate for Payer: Health EOS Commercial |
$4,260.43
|
| Rate for Payer: HFN Commercial |
$4,404.04
|
| Rate for Payer: Multiplan Commercial |
$3,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,404.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,345.63
|
| Rate for Payer: Quartz Commercial |
$2,872.20
|
| Rate for Payer: WEA Trust Commercial |
$2,632.85
|
| Rate for Payer: WPS Commercial |
$3,545.73
|
|
|
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 |
$221.76 |
| Max. Negotiated Rate |
$3,168.00 |
| Rate for Payer: Aetna Commercial |
$712.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.12
|
| Rate for Payer: Aetna Managed Medicare |
$221.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$514.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$396.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$380.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$419.76
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$728.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$443.20
|
| Rate for Payer: Health EOS Commercial |
$704.88
|
| Rate for Payer: HFN Commercial |
$728.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$594.00
|
| Rate for Payer: Multiplan Commercial |
$633.60
|
| Rate for Payer: NAPHCARE Commercial |
$475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$728.64
|
| Rate for Payer: Quartz Beloit One Network |
$388.08
|
| Rate for Payer: Quartz Commercial |
$514.80
|
| Rate for Payer: Quartz Medicare Advantage |
$475.20
|
| Rate for Payer: The Alliance Commercial |
$3,168.00
|
| Rate for Payer: WEA Trust Commercial |
$435.60
|
| Rate for Payer: WPS Commercial |
$586.63
|
|
|
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 |
$388.08 |
| Max. Negotiated Rate |
$728.64 |
| Rate for Payer: Aetna Commercial |
$712.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$419.76
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$728.64
|
| Rate for Payer: Health EOS Commercial |
$704.88
|
| Rate for Payer: HFN Commercial |
$728.64
|
| Rate for Payer: Multiplan Commercial |
$633.60
|
| Rate for Payer: NAPHCARE Commercial |
$475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$728.64
|
| Rate for Payer: Quartz Beloit One Network |
$388.08
|
| Rate for Payer: Quartz Commercial |
$475.20
|
| Rate for Payer: WEA Trust Commercial |
$435.60
|
| Rate for Payer: WPS Commercial |
$586.63
|
|
|
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 |
$1,786.54 |
| Max. Negotiated Rate |
$3,354.32 |
| Rate for Payer: Aetna Commercial |
$3,281.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,135.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,932.38
|
| Rate for Payer: Cash Price |
$1,093.80
|
| Rate for Payer: Cigna Commercial |
$3,354.32
|
| Rate for Payer: Health EOS Commercial |
$3,244.94
|
| Rate for Payer: HFN Commercial |
$3,354.32
|
| Rate for Payer: Multiplan Commercial |
$2,916.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,187.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,354.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,786.54
|
| Rate for Payer: Quartz Commercial |
$2,187.60
|
| Rate for Payer: WEA Trust Commercial |
$2,005.30
|
| Rate for Payer: WPS Commercial |
$2,700.59
|
|
|
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 |
$1,020.88 |
| Max. Negotiated Rate |
$14,584.00 |
| Rate for Payer: Aetna Commercial |
$3,281.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,135.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,020.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,369.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,823.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,750.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,932.38
|
| Rate for Payer: Cash Price |
$1,093.80
|
| Rate for Payer: Cigna Commercial |
$3,354.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,040.30
|
| Rate for Payer: Health EOS Commercial |
$3,244.94
|
| Rate for Payer: HFN Commercial |
$3,354.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,734.50
|
| Rate for Payer: Multiplan Commercial |
$2,916.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,187.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,354.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,786.54
|
| Rate for Payer: Quartz Commercial |
$2,369.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,187.60
|
| Rate for Payer: The Alliance Commercial |
$14,584.00
|
| Rate for Payer: WEA Trust Commercial |
$2,005.30
|
| Rate for Payer: WPS Commercial |
$2,700.59
|
|
|
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 |
$230.16 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$739.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$706.92
|
| Rate for Payer: Aetna Managed Medicare |
$230.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$534.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$411.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$394.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$435.66
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$756.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$459.99
|
| Rate for Payer: Health EOS Commercial |
$731.58
|
| Rate for Payer: HFN Commercial |
$756.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$616.50
|
| Rate for Payer: Multiplan Commercial |
$657.60
|
| Rate for Payer: NAPHCARE Commercial |
$493.20
|
| Rate for Payer: Preferred Network Access Commercial |
$756.24
|
| Rate for Payer: Quartz Beloit One Network |
$402.78
|
| Rate for Payer: Quartz Commercial |
$534.30
|
| Rate for Payer: Quartz Medicare Advantage |
$493.20
|
| Rate for Payer: The Alliance Commercial |
$3,288.00
|
| Rate for Payer: WEA Trust Commercial |
$452.10
|
| Rate for Payer: WPS Commercial |
$608.86
|
|
|
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 |
$402.78 |
| Max. Negotiated Rate |
$756.24 |
| Rate for Payer: Aetna Commercial |
$739.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$706.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$435.66
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$756.24
|
| Rate for Payer: Health EOS Commercial |
$731.58
|
| Rate for Payer: HFN Commercial |
$756.24
|
| Rate for Payer: Multiplan Commercial |
$657.60
|
| Rate for Payer: NAPHCARE Commercial |
$493.20
|
| Rate for Payer: Preferred Network Access Commercial |
$756.24
|
| Rate for Payer: Quartz Beloit One Network |
$402.78
|
| Rate for Payer: Quartz Commercial |
$493.20
|
| Rate for Payer: WEA Trust Commercial |
$452.10
|
| Rate for Payer: WPS Commercial |
$608.86
|
|
|
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 |
$361.13 |
| Max. Negotiated Rate |
$678.04 |
| Rate for Payer: Aetna Commercial |
$663.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$633.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$390.61
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$678.04
|
| Rate for Payer: Health EOS Commercial |
$655.93
|
| Rate for Payer: HFN Commercial |
$678.04
|
| Rate for Payer: Multiplan Commercial |
$589.60
|
| Rate for Payer: NAPHCARE Commercial |
$442.20
|
| Rate for Payer: Preferred Network Access Commercial |
$678.04
|
| Rate for Payer: Quartz Beloit One Network |
$361.13
|
| Rate for Payer: Quartz Commercial |
$442.20
|
| Rate for Payer: WEA Trust Commercial |
$405.35
|
| Rate for Payer: WPS Commercial |
$545.90
|
|
|
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 |
$206.36 |
| Max. Negotiated Rate |
$2,948.00 |
| Rate for Payer: Aetna Commercial |
$663.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$633.82
|
| Rate for Payer: Aetna Managed Medicare |
$206.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$479.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$368.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$353.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$390.61
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$678.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$412.43
|
| Rate for Payer: Health EOS Commercial |
$655.93
|
| Rate for Payer: HFN Commercial |
$678.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$552.75
|
| Rate for Payer: Multiplan Commercial |
$589.60
|
| Rate for Payer: NAPHCARE Commercial |
$442.20
|
| Rate for Payer: Preferred Network Access Commercial |
$678.04
|
| Rate for Payer: Quartz Beloit One Network |
$361.13
|
| Rate for Payer: Quartz Commercial |
$479.05
|
| Rate for Payer: Quartz Medicare Advantage |
$442.20
|
| Rate for Payer: The Alliance Commercial |
$2,948.00
|
| Rate for Payer: WEA Trust Commercial |
$405.35
|
| Rate for Payer: WPS Commercial |
$545.90
|
|
|
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 |
$361.13 |
| Max. Negotiated Rate |
$678.04 |
| Rate for Payer: Aetna Commercial |
$663.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$633.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$390.61
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$678.04
|
| Rate for Payer: Health EOS Commercial |
$655.93
|
| Rate for Payer: HFN Commercial |
$678.04
|
| Rate for Payer: Multiplan Commercial |
$589.60
|
| Rate for Payer: NAPHCARE Commercial |
$442.20
|
| Rate for Payer: Preferred Network Access Commercial |
$678.04
|
| Rate for Payer: Quartz Beloit One Network |
$361.13
|
| Rate for Payer: Quartz Commercial |
$442.20
|
| Rate for Payer: WEA Trust Commercial |
$405.35
|
| Rate for Payer: WPS Commercial |
$545.90
|
|
|
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 |
$206.36 |
| Max. Negotiated Rate |
$2,948.00 |
| Rate for Payer: Aetna Commercial |
$663.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$633.82
|
| Rate for Payer: Aetna Managed Medicare |
$206.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$479.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$368.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$353.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$390.61
|
| Rate for Payer: Cash Price |
$221.10
|
| Rate for Payer: Cigna Commercial |
$678.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$412.43
|
| Rate for Payer: Health EOS Commercial |
$655.93
|
| Rate for Payer: HFN Commercial |
$678.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$552.75
|
| Rate for Payer: Multiplan Commercial |
$589.60
|
| Rate for Payer: NAPHCARE Commercial |
$442.20
|
| Rate for Payer: Preferred Network Access Commercial |
$678.04
|
| Rate for Payer: Quartz Beloit One Network |
$361.13
|
| Rate for Payer: Quartz Commercial |
$479.05
|
| Rate for Payer: Quartz Medicare Advantage |
$442.20
|
| Rate for Payer: The Alliance Commercial |
$2,948.00
|
| Rate for Payer: WEA Trust Commercial |
$405.35
|
| Rate for Payer: WPS Commercial |
$545.90
|
|
