|
PLATE 1/3 TUBULAR 8HL 241.38
|
Facility
|
OP
|
$1,064.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$309.84 |
| Max. Negotiated Rate |
$1,018.04 |
| Rate for Payer: Aetna Commercial |
$995.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$951.64
|
| Rate for Payer: Aetna Managed Medicare |
$309.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$719.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$553.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$531.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$586.48
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: Cigna Commercial |
$1,018.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$619.25
|
| Rate for Payer: Health EOS Commercial |
$984.84
|
| Rate for Payer: HFN Commercial |
$1,018.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$829.92
|
| Rate for Payer: Multiplan Commercial |
$885.25
|
| Rate for Payer: NAPHCARE Commercial |
$663.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,018.04
|
| Rate for Payer: Quartz Beloit One Network |
$542.21
|
| Rate for Payer: Quartz Commercial |
$719.26
|
| Rate for Payer: Quartz Medicare Advantage |
$663.94
|
| Rate for Payer: The Alliance Commercial |
$553.28
|
| Rate for Payer: WEA Trust Commercial |
$608.61
|
| Rate for Payer: WPS Commercial |
$819.60
|
|
|
PLATE 1/3 TUBULAR 9HL 241.39
|
Facility
|
IP
|
$983.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5547452
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$500.94 |
| Max. Negotiated Rate |
$940.53 |
| Rate for Payer: Aetna Commercial |
$920.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$879.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$541.83
|
| Rate for Payer: Cash Price |
$294.90
|
| Rate for Payer: Cigna Commercial |
$940.53
|
| Rate for Payer: Health EOS Commercial |
$909.86
|
| Rate for Payer: HFN Commercial |
$940.53
|
| Rate for Payer: Multiplan Commercial |
$817.86
|
| Rate for Payer: Preferred Network Access Commercial |
$940.53
|
| Rate for Payer: Quartz Beloit One Network |
$500.94
|
| Rate for Payer: Quartz Commercial |
$613.39
|
| Rate for Payer: WEA Trust Commercial |
$562.28
|
| Rate for Payer: WPS Commercial |
$757.20
|
|
|
PLATE 1/3 TUBULAR 9HL 241.39
|
Facility
|
OP
|
$983.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5547452
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$286.25 |
| Max. Negotiated Rate |
$940.53 |
| Rate for Payer: Aetna Commercial |
$920.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$879.20
|
| Rate for Payer: Aetna Managed Medicare |
$286.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$664.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$511.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$490.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$541.83
|
| Rate for Payer: Cash Price |
$294.90
|
| Rate for Payer: Cigna Commercial |
$940.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$572.11
|
| Rate for Payer: Health EOS Commercial |
$909.86
|
| Rate for Payer: HFN Commercial |
$940.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$766.74
|
| Rate for Payer: Multiplan Commercial |
$817.86
|
| Rate for Payer: NAPHCARE Commercial |
$613.39
|
| Rate for Payer: Preferred Network Access Commercial |
$940.53
|
| Rate for Payer: Quartz Beloit One Network |
$500.94
|
| Rate for Payer: Quartz Commercial |
$664.51
|
| Rate for Payer: Quartz Medicare Advantage |
$613.39
|
| Rate for Payer: The Alliance Commercial |
$511.16
|
| Rate for Payer: WEA Trust Commercial |
$562.28
|
| Rate for Payer: WPS Commercial |
$757.20
|
|
|
PLATE 14H 3.5 LCP 223.641
|
Facility
|
OP
|
$2,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$754.50 |
| Max. Negotiated Rate |
$2,479.07 |
| Rate for Payer: Aetna Commercial |
$2,425.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,317.39
|
| Rate for Payer: Aetna Managed Medicare |
$754.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,751.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,347.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,293.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.16
|
| Rate for Payer: Cash Price |
$777.30
|
| Rate for Payer: Cigna Commercial |
$2,479.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,507.96
|
| Rate for Payer: Health EOS Commercial |
$2,398.23
|
| Rate for Payer: HFN Commercial |
$2,479.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,020.98
|
| Rate for Payer: Multiplan Commercial |
$2,155.71
|
| Rate for Payer: NAPHCARE Commercial |
$1,616.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,479.07
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.37
|
| Rate for Payer: Quartz Commercial |
$1,751.52
|
| Rate for Payer: Quartz Medicare Advantage |
$1,616.78
|
| Rate for Payer: The Alliance Commercial |
$1,347.32
|
| Rate for Payer: WEA Trust Commercial |
$1,482.05
|
| Rate for Payer: WPS Commercial |
$1,995.85
|
|
|
PLATE 14H 3.5 LCP 223.641
|
Facility
|
IP
|
$2,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,320.37 |
| Max. Negotiated Rate |
$2,479.07 |
| Rate for Payer: Aetna Commercial |
$2,425.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,317.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,428.16
|
| Rate for Payer: Cash Price |
$777.30
|
| Rate for Payer: Cigna Commercial |
$2,479.07
|
| Rate for Payer: Health EOS Commercial |
$2,398.23
|
| Rate for Payer: HFN Commercial |
$2,479.07
|
| Rate for Payer: Multiplan Commercial |
$2,155.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,479.07
|
| Rate for Payer: Quartz Beloit One Network |
$1,320.37
|
| Rate for Payer: Quartz Commercial |
$1,616.78
|
| Rate for Payer: WEA Trust Commercial |
$1,482.05
|
| Rate for Payer: WPS Commercial |
$1,995.85
|
|
|
PLATE 14H LT CONDYLAR 222.665
|
Facility
|
OP
|
$4,836.00
|
|
| Hospital Charge Code |
2966676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,408.24 |
| Max. Negotiated Rate |
$4,627.08 |
| Rate for Payer: Aetna Managed Medicare |
$1,408.24
|
| Rate for Payer: Aetna Commercial |
$4,526.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,269.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,514.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,414.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.60
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,627.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.55
|
| Rate for Payer: Health EOS Commercial |
$4,476.20
|
| Rate for Payer: HFN Commercial |
$4,627.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,772.08
|
| Rate for Payer: Multiplan Commercial |
$4,023.55
|
| Rate for Payer: NAPHCARE Commercial |
$3,017.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.43
|
| Rate for Payer: Quartz Commercial |
$3,269.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,017.66
|
| Rate for Payer: The Alliance Commercial |
$2,514.72
|
| Rate for Payer: WEA Trust Commercial |
$2,766.19
|
| Rate for Payer: WPS Commercial |
$3,725.17
|
|
|
PLATE 14H LT CONDYLAR 222.665
|
Facility
|
IP
|
$4,836.00
|
|
| Hospital Charge Code |
2966676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.43 |
| Max. Negotiated Rate |
$4,627.08 |
| Rate for Payer: Aetna Commercial |
$4,526.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.60
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,627.08
|
| Rate for Payer: Health EOS Commercial |
$4,476.20
|
| Rate for Payer: HFN Commercial |
$4,627.08
|
| Rate for Payer: Multiplan Commercial |
$4,023.55
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.43
|
| Rate for Payer: Quartz Commercial |
$3,017.66
|
| Rate for Payer: WEA Trust Commercial |
$2,766.19
|
| Rate for Payer: WPS Commercial |
$3,725.17
|
|
|
PLATE 14H LT PROX/TIB 240.047
|
Facility
|
IP
|
$6,958.00
|
|
| Hospital Charge Code |
2966677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,545.80 |
| Max. Negotiated Rate |
$6,657.41 |
| Rate for Payer: Aetna Commercial |
$6,512.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,223.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,835.25
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,657.41
|
| Rate for Payer: Health EOS Commercial |
$6,440.32
|
| Rate for Payer: HFN Commercial |
$6,657.41
|
| Rate for Payer: Multiplan Commercial |
$5,789.06
|
| Rate for Payer: Preferred Network Access Commercial |
$6,657.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.80
|
| Rate for Payer: Quartz Commercial |
$4,341.79
|
| Rate for Payer: WEA Trust Commercial |
$3,979.98
|
| Rate for Payer: WPS Commercial |
$5,359.75
|
|
|
PLATE 14H LT PROX/TIB 240.047
|
Facility
|
OP
|
$6,958.00
|
|
| Hospital Charge Code |
2966677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,026.17 |
| Max. Negotiated Rate |
$6,657.41 |
| Rate for Payer: Aetna Commercial |
$6,512.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,223.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,026.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,703.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,618.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,473.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,835.25
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,657.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,049.56
|
| Rate for Payer: Health EOS Commercial |
$6,440.32
|
| Rate for Payer: HFN Commercial |
$6,657.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,427.24
|
| Rate for Payer: Multiplan Commercial |
$5,789.06
|
| Rate for Payer: NAPHCARE Commercial |
$4,341.79
|
| Rate for Payer: Preferred Network Access Commercial |
$6,657.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.80
|
| Rate for Payer: Quartz Commercial |
$4,703.61
|
| Rate for Payer: Quartz Medicare Advantage |
$4,341.79
|
| Rate for Payer: The Alliance Commercial |
$3,618.16
|
| Rate for Payer: WEA Trust Commercial |
$3,979.98
|
| Rate for Payer: WPS Commercial |
$5,359.75
|
|
|
PLATE 14H RT CONDYLAR 222.664
|
Facility
|
IP
|
$4,836.00
|
|
| Hospital Charge Code |
2966675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.43 |
| Max. Negotiated Rate |
$4,627.08 |
| Rate for Payer: Aetna Commercial |
$4,526.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.60
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,627.08
|
| Rate for Payer: Health EOS Commercial |
$4,476.20
|
| Rate for Payer: HFN Commercial |
$4,627.08
|
| Rate for Payer: Multiplan Commercial |
$4,023.55
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.43
|
| Rate for Payer: Quartz Commercial |
$3,017.66
|
| Rate for Payer: WEA Trust Commercial |
$2,766.19
|
| Rate for Payer: WPS Commercial |
$3,725.17
|
|
|
PLATE 14H RT CONDYLAR 222.664
|
Facility
|
OP
|
$4,836.00
|
|
| Hospital Charge Code |
2966675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,408.24 |
| Max. Negotiated Rate |
$4,627.08 |
| Rate for Payer: Aetna Commercial |
$4,526.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,408.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,269.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,514.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,414.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.60
|
| Rate for Payer: Cash Price |
$1,450.80
|
| Rate for Payer: Cigna Commercial |
$4,627.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.55
|
| Rate for Payer: Health EOS Commercial |
$4,476.20
|
| Rate for Payer: HFN Commercial |
$4,627.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,772.08
|
| Rate for Payer: Multiplan Commercial |
$4,023.55
|
| Rate for Payer: NAPHCARE Commercial |
$3,017.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.43
|
| Rate for Payer: Quartz Commercial |
$3,269.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,017.66
|
| Rate for Payer: The Alliance Commercial |
$2,514.72
|
| Rate for Payer: WEA Trust Commercial |
$2,766.19
|
| Rate for Payer: WPS Commercial |
$3,725.17
|
|
|
PLATE 14H RT PROX/TIB 240.046
|
Facility
|
OP
|
$6,958.00
|
|
| Hospital Charge Code |
2966678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,026.17 |
| Max. Negotiated Rate |
$6,657.41 |
| Rate for Payer: Aetna Commercial |
$6,512.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,223.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,026.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,703.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,618.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,473.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,835.25
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,657.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,049.56
|
| Rate for Payer: Health EOS Commercial |
$6,440.32
|
| Rate for Payer: HFN Commercial |
$6,657.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,427.24
|
| Rate for Payer: Multiplan Commercial |
$5,789.06
|
| Rate for Payer: NAPHCARE Commercial |
$4,341.79
|
| Rate for Payer: Preferred Network Access Commercial |
$6,657.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.80
|
| Rate for Payer: Quartz Commercial |
$4,703.61
|
| Rate for Payer: Quartz Medicare Advantage |
$4,341.79
|
| Rate for Payer: The Alliance Commercial |
$3,618.16
|
| Rate for Payer: WEA Trust Commercial |
$3,979.98
|
| Rate for Payer: WPS Commercial |
$5,359.75
|
|
|
PLATE 14H RT PROX/TIB 240.046
|
Facility
|
IP
|
$6,958.00
|
|
| Hospital Charge Code |
2966678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,545.80 |
| Max. Negotiated Rate |
$6,657.41 |
| Rate for Payer: Aetna Commercial |
$6,512.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,223.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,835.25
|
| Rate for Payer: Cash Price |
$2,087.40
|
| Rate for Payer: Cigna Commercial |
$6,657.41
|
| Rate for Payer: Health EOS Commercial |
$6,440.32
|
| Rate for Payer: HFN Commercial |
$6,657.41
|
| Rate for Payer: Multiplan Commercial |
$5,789.06
|
| Rate for Payer: Preferred Network Access Commercial |
$6,657.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.80
|
| Rate for Payer: Quartz Commercial |
$4,341.79
|
| Rate for Payer: WEA Trust Commercial |
$3,979.98
|
| Rate for Payer: WPS Commercial |
$5,359.75
|
|
|
PLATE 1/4 TUBULAR 3HL 242.03
|
Facility
|
OP
|
$434.00
|
|
| Hospital Charge Code |
2966656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.38 |
| Max. Negotiated Rate |
$415.25 |
| Rate for Payer: Aetna Commercial |
$406.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.17
|
| Rate for Payer: Aetna Managed Medicare |
$126.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$293.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$225.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$216.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.22
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$415.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.59
|
| Rate for Payer: Health EOS Commercial |
$401.71
|
| Rate for Payer: HFN Commercial |
$415.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$338.52
|
| Rate for Payer: Multiplan Commercial |
$361.09
|
| Rate for Payer: NAPHCARE Commercial |
$270.82
|
| Rate for Payer: Preferred Network Access Commercial |
$415.25
|
| Rate for Payer: Quartz Beloit One Network |
$221.17
|
| Rate for Payer: Quartz Commercial |
$293.38
|
| Rate for Payer: Quartz Medicare Advantage |
$270.82
|
| Rate for Payer: The Alliance Commercial |
$225.68
|
| Rate for Payer: WEA Trust Commercial |
$248.25
|
| Rate for Payer: WPS Commercial |
$334.31
|
|
|
PLATE 1/4 TUBULAR 3HL 242.03
|
Facility
|
IP
|
$434.00
|
|
| Hospital Charge Code |
2966656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.17 |
| Max. Negotiated Rate |
$415.25 |
| Rate for Payer: Aetna Commercial |
$406.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.22
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$415.25
|
| Rate for Payer: Health EOS Commercial |
$401.71
|
| Rate for Payer: HFN Commercial |
$415.25
|
| Rate for Payer: Multiplan Commercial |
$361.09
|
| Rate for Payer: Preferred Network Access Commercial |
$415.25
|
| Rate for Payer: Quartz Beloit One Network |
$221.17
|
| Rate for Payer: Quartz Commercial |
$270.82
|
| Rate for Payer: WEA Trust Commercial |
$248.25
|
| Rate for Payer: WPS Commercial |
$334.31
|
|
|
PLATE 1/4 TUBULAR 4HL 242.04
|
Facility
|
IP
|
$978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$498.39 |
| Max. Negotiated Rate |
$935.75 |
| Rate for Payer: Aetna Commercial |
$915.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$874.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$539.07
|
| Rate for Payer: Cash Price |
$293.40
|
| Rate for Payer: Cigna Commercial |
$935.75
|
| Rate for Payer: Health EOS Commercial |
$905.24
|
| Rate for Payer: HFN Commercial |
$935.75
|
| Rate for Payer: Multiplan Commercial |
$813.70
|
| Rate for Payer: Preferred Network Access Commercial |
$935.75
|
| Rate for Payer: Quartz Beloit One Network |
$498.39
|
| Rate for Payer: Quartz Commercial |
$610.27
|
| Rate for Payer: WEA Trust Commercial |
$559.42
|
| Rate for Payer: WPS Commercial |
$753.35
|
|
|
PLATE 1/4 TUBULAR 4HL 242.04
|
Facility
|
OP
|
$978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$284.79 |
| Max. Negotiated Rate |
$935.75 |
| Rate for Payer: Aetna Commercial |
$915.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$874.72
|
| Rate for Payer: Aetna Managed Medicare |
$284.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$661.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$508.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$488.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$539.07
|
| Rate for Payer: Cash Price |
$293.40
|
| Rate for Payer: Cigna Commercial |
$935.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$569.20
|
| Rate for Payer: Health EOS Commercial |
$905.24
|
| Rate for Payer: HFN Commercial |
$935.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$762.84
|
| Rate for Payer: Multiplan Commercial |
$813.70
|
| Rate for Payer: NAPHCARE Commercial |
$610.27
|
| Rate for Payer: Preferred Network Access Commercial |
$935.75
|
| Rate for Payer: Quartz Beloit One Network |
$498.39
|
| Rate for Payer: Quartz Commercial |
$661.13
|
| Rate for Payer: Quartz Medicare Advantage |
$610.27
|
| Rate for Payer: The Alliance Commercial |
$508.56
|
| Rate for Payer: WEA Trust Commercial |
$559.42
|
| Rate for Payer: WPS Commercial |
$753.35
|
|
|
PLATE 1/4 TUBULAR 5HL 242.05
|
Facility
|
IP
|
$547.00
|
|
| Hospital Charge Code |
2966658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$278.75 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$341.33
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
PLATE 1/4 TUBULAR 5HL 242.05
|
Facility
|
OP
|
$547.00
|
|
| Hospital Charge Code |
2966658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$159.29 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Aetna Managed Medicare |
$159.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$284.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$273.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.35
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.66
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: NAPHCARE Commercial |
$341.33
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$369.77
|
| Rate for Payer: Quartz Medicare Advantage |
$341.33
|
| Rate for Payer: The Alliance Commercial |
$284.44
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
PLATE 1/4 TUBULAR 6HL 242.06
|
Facility
|
OP
|
$1,145.00
|
|
| Hospital Charge Code |
2966659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.42 |
| Max. Negotiated Rate |
$1,095.54 |
| Rate for Payer: Aetna Commercial |
$1,071.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,024.09
|
| Rate for Payer: Aetna Managed Medicare |
$333.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$595.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$571.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.12
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$1,095.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$666.39
|
| Rate for Payer: Health EOS Commercial |
$1,059.81
|
| Rate for Payer: HFN Commercial |
$1,095.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$893.10
|
| Rate for Payer: Multiplan Commercial |
$952.64
|
| Rate for Payer: NAPHCARE Commercial |
$714.48
|
| Rate for Payer: Preferred Network Access Commercial |
$1,095.54
|
| Rate for Payer: Quartz Beloit One Network |
$583.49
|
| Rate for Payer: Quartz Commercial |
$774.02
|
| Rate for Payer: Quartz Medicare Advantage |
$714.48
|
| Rate for Payer: The Alliance Commercial |
$595.40
|
| Rate for Payer: WEA Trust Commercial |
$654.94
|
| Rate for Payer: WPS Commercial |
$881.99
|
|
|
PLATE 1/4 TUBULAR 6HL 242.06
|
Facility
|
IP
|
$1,145.00
|
|
| Hospital Charge Code |
2966659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$583.49 |
| Max. Negotiated Rate |
$1,095.54 |
| Rate for Payer: Aetna Commercial |
$1,071.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,024.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.12
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$1,095.54
|
| Rate for Payer: Health EOS Commercial |
$1,059.81
|
| Rate for Payer: HFN Commercial |
$1,095.54
|
| Rate for Payer: Multiplan Commercial |
$952.64
|
| Rate for Payer: Preferred Network Access Commercial |
$1,095.54
|
| Rate for Payer: Quartz Beloit One Network |
$583.49
|
| Rate for Payer: Quartz Commercial |
$714.48
|
| Rate for Payer: WEA Trust Commercial |
$654.94
|
| Rate for Payer: WPS Commercial |
$881.99
|
|
|
PLATE 1/4 TUBULAR 7HL 242.07
|
Facility
|
OP
|
$627.00
|
|
| Hospital Charge Code |
2966660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$182.58 |
| Max. Negotiated Rate |
$599.91 |
| Rate for Payer: Aetna Commercial |
$586.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$560.79
|
| Rate for Payer: Aetna Managed Medicare |
$182.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$313.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.60
|
| Rate for Payer: Cash Price |
$188.10
|
| Rate for Payer: Cigna Commercial |
$599.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$364.91
|
| Rate for Payer: Health EOS Commercial |
$580.35
|
| Rate for Payer: HFN Commercial |
$599.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$489.06
|
| Rate for Payer: Multiplan Commercial |
$521.66
|
| Rate for Payer: NAPHCARE Commercial |
$391.25
|
| Rate for Payer: Preferred Network Access Commercial |
$599.91
|
| Rate for Payer: Quartz Beloit One Network |
$319.52
|
| Rate for Payer: Quartz Commercial |
$423.85
|
| Rate for Payer: Quartz Medicare Advantage |
$391.25
|
| Rate for Payer: The Alliance Commercial |
$326.04
|
| Rate for Payer: WEA Trust Commercial |
$358.64
|
| Rate for Payer: WPS Commercial |
$482.98
|
|
|
PLATE 1/4 TUBULAR 7HL 242.07
|
Facility
|
IP
|
$627.00
|
|
| Hospital Charge Code |
2966660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$319.52 |
| Max. Negotiated Rate |
$599.91 |
| Rate for Payer: Aetna Commercial |
$586.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$560.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.60
|
| Rate for Payer: Cash Price |
$188.10
|
| Rate for Payer: Cigna Commercial |
$599.91
|
| Rate for Payer: Health EOS Commercial |
$580.35
|
| Rate for Payer: HFN Commercial |
$599.91
|
| Rate for Payer: Multiplan Commercial |
$521.66
|
| Rate for Payer: Preferred Network Access Commercial |
$599.91
|
| Rate for Payer: Quartz Beloit One Network |
$319.52
|
| Rate for Payer: Quartz Commercial |
$391.25
|
| Rate for Payer: WEA Trust Commercial |
$358.64
|
| Rate for Payer: WPS Commercial |
$482.98
|
|
|
PLATE 1/4 TUBULAR 8HL 242.08
|
Facility
|
IP
|
$1,776.00
|
|
| Hospital Charge Code |
2966661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$905.05 |
| Max. Negotiated Rate |
$1,699.28 |
| Rate for Payer: Aetna Commercial |
$1,662.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,588.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.93
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: Cigna Commercial |
$1,699.28
|
| Rate for Payer: Health EOS Commercial |
$1,643.87
|
| Rate for Payer: HFN Commercial |
$1,699.28
|
| Rate for Payer: Multiplan Commercial |
$1,477.63
|
| Rate for Payer: Preferred Network Access Commercial |
$1,699.28
|
| Rate for Payer: Quartz Beloit One Network |
$905.05
|
| Rate for Payer: Quartz Commercial |
$1,108.22
|
| Rate for Payer: WEA Trust Commercial |
$1,015.87
|
| Rate for Payer: WPS Commercial |
$1,368.05
|
|
|
PLATE 1/4 TUBULAR 8HL 242.08
|
Facility
|
OP
|
$1,776.00
|
|
| Hospital Charge Code |
2966661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$517.17 |
| Max. Negotiated Rate |
$1,699.28 |
| Rate for Payer: Aetna Commercial |
$1,662.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,588.45
|
| Rate for Payer: Aetna Managed Medicare |
$517.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,200.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$923.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$886.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.93
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: Cigna Commercial |
$1,699.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,033.63
|
| Rate for Payer: Health EOS Commercial |
$1,643.87
|
| Rate for Payer: HFN Commercial |
$1,699.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,385.28
|
| Rate for Payer: Multiplan Commercial |
$1,477.63
|
| Rate for Payer: NAPHCARE Commercial |
$1,108.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,699.28
|
| Rate for Payer: Quartz Beloit One Network |
$905.05
|
| Rate for Payer: Quartz Commercial |
$1,200.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,108.22
|
| Rate for Payer: The Alliance Commercial |
$923.52
|
| Rate for Payer: WEA Trust Commercial |
$1,015.87
|
| Rate for Payer: WPS Commercial |
$1,368.05
|
|
