|
PLATE AMBI 135DEG 2HL 124121
|
Facility
|
OP
|
$7,922.00
|
|
| Hospital Charge Code |
4494005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,306.89 |
| Max. Negotiated Rate |
$7,579.77 |
| Rate for Payer: Aetna Commercial |
$7,414.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,085.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,306.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,355.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,119.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,954.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,366.61
|
| Rate for Payer: Cash Price |
$2,376.60
|
| Rate for Payer: Cigna Commercial |
$7,579.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,610.60
|
| Rate for Payer: Health EOS Commercial |
$7,332.60
|
| Rate for Payer: HFN Commercial |
$7,579.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,179.16
|
| Rate for Payer: Multiplan Commercial |
$6,591.10
|
| Rate for Payer: NAPHCARE Commercial |
$4,943.33
|
| Rate for Payer: Preferred Network Access Commercial |
$7,579.77
|
| Rate for Payer: Quartz Beloit One Network |
$4,037.05
|
| Rate for Payer: Quartz Commercial |
$5,355.27
|
| Rate for Payer: Quartz Medicare Advantage |
$4,943.33
|
| Rate for Payer: The Alliance Commercial |
$4,119.44
|
| Rate for Payer: WEA Trust Commercial |
$4,531.38
|
| Rate for Payer: WPS Commercial |
$6,102.32
|
|
|
PLATE AMBI 135DEG 2HL 124121
|
Facility
|
IP
|
$7,922.00
|
|
| Hospital Charge Code |
4494005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,037.05 |
| Max. Negotiated Rate |
$7,579.77 |
| Rate for Payer: Aetna Commercial |
$7,414.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,085.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,366.61
|
| Rate for Payer: Cash Price |
$2,376.60
|
| Rate for Payer: Cigna Commercial |
$7,579.77
|
| Rate for Payer: Health EOS Commercial |
$7,332.60
|
| Rate for Payer: HFN Commercial |
$7,579.77
|
| Rate for Payer: Multiplan Commercial |
$6,591.10
|
| Rate for Payer: Preferred Network Access Commercial |
$7,579.77
|
| Rate for Payer: Quartz Beloit One Network |
$4,037.05
|
| Rate for Payer: Quartz Commercial |
$4,943.33
|
| Rate for Payer: WEA Trust Commercial |
$4,531.38
|
| Rate for Payer: WPS Commercial |
$6,102.32
|
|
|
PLATE AMBI 135DEG 3HL 124126
|
Facility
|
OP
|
$3,707.00
|
|
| Hospital Charge Code |
2966021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,079.48 |
| Max. Negotiated Rate |
$3,546.86 |
| Rate for Payer: Aetna Commercial |
$3,469.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,315.54
|
| Rate for Payer: Aetna Managed Medicare |
$1,079.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,505.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,927.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,850.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,043.30
|
| Rate for Payer: Cash Price |
$1,112.10
|
| Rate for Payer: Cigna Commercial |
$3,546.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,157.47
|
| Rate for Payer: Health EOS Commercial |
$3,431.20
|
| Rate for Payer: HFN Commercial |
$3,546.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,891.46
|
| Rate for Payer: Multiplan Commercial |
$3,084.22
|
| Rate for Payer: NAPHCARE Commercial |
$2,313.17
|
| Rate for Payer: Preferred Network Access Commercial |
$3,546.86
|
| Rate for Payer: Quartz Beloit One Network |
$1,889.09
|
| Rate for Payer: Quartz Commercial |
$2,505.93
|
| Rate for Payer: Quartz Medicare Advantage |
$2,313.17
|
| Rate for Payer: The Alliance Commercial |
$1,927.64
|
| Rate for Payer: WEA Trust Commercial |
$2,120.40
|
| Rate for Payer: WPS Commercial |
$2,855.50
|
|
|
PLATE AMBI 135DEG 3HL 124126
|
Facility
|
IP
|
$3,707.00
|
|
| Hospital Charge Code |
2966021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,889.09 |
| Max. Negotiated Rate |
$3,546.86 |
| Rate for Payer: Aetna Commercial |
$3,469.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,315.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,043.30
|
| Rate for Payer: Cash Price |
$1,112.10
|
| Rate for Payer: Cigna Commercial |
$3,546.86
|
| Rate for Payer: Health EOS Commercial |
$3,431.20
|
| Rate for Payer: HFN Commercial |
$3,546.86
|
| Rate for Payer: Multiplan Commercial |
$3,084.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,546.86
|
| Rate for Payer: Quartz Beloit One Network |
$1,889.09
|
| Rate for Payer: Quartz Commercial |
$2,313.17
|
| Rate for Payer: WEA Trust Commercial |
$2,120.40
|
| Rate for Payer: WPS Commercial |
$2,855.50
|
|
|
PLATE AMBI 135DEG 4HL 124131
|
Facility
|
IP
|
$3,707.00
|
|
| Hospital Charge Code |
2966022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,889.09 |
| Max. Negotiated Rate |
$3,546.86 |
| Rate for Payer: Aetna Commercial |
$3,469.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,315.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,043.30
|
| Rate for Payer: Cash Price |
$1,112.10
|
| Rate for Payer: Cigna Commercial |
$3,546.86
|
| Rate for Payer: Health EOS Commercial |
$3,431.20
|
| Rate for Payer: HFN Commercial |
$3,546.86
|
| Rate for Payer: Multiplan Commercial |
$3,084.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,546.86
|
| Rate for Payer: Quartz Beloit One Network |
$1,889.09
|
| Rate for Payer: Quartz Commercial |
$2,313.17
|
| Rate for Payer: WEA Trust Commercial |
$2,120.40
|
| Rate for Payer: WPS Commercial |
$2,855.50
|
|
|
PLATE AMBI 135DEG 4HL 124131
|
Facility
|
OP
|
$3,707.00
|
|
| Hospital Charge Code |
2966022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,079.48 |
| Max. Negotiated Rate |
$3,546.86 |
| Rate for Payer: Aetna Commercial |
$3,469.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,315.54
|
| Rate for Payer: Aetna Managed Medicare |
$1,079.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,505.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,927.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,850.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,043.30
|
| Rate for Payer: Cash Price |
$1,112.10
|
| Rate for Payer: Cigna Commercial |
$3,546.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,157.47
|
| Rate for Payer: Health EOS Commercial |
$3,431.20
|
| Rate for Payer: HFN Commercial |
$3,546.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,891.46
|
| Rate for Payer: Multiplan Commercial |
$3,084.22
|
| Rate for Payer: NAPHCARE Commercial |
$2,313.17
|
| Rate for Payer: Preferred Network Access Commercial |
$3,546.86
|
| Rate for Payer: Quartz Beloit One Network |
$1,889.09
|
| Rate for Payer: Quartz Commercial |
$2,505.93
|
| Rate for Payer: Quartz Medicare Advantage |
$2,313.17
|
| Rate for Payer: The Alliance Commercial |
$1,927.64
|
| Rate for Payer: WEA Trust Commercial |
$2,120.40
|
| Rate for Payer: WPS Commercial |
$2,855.50
|
|
|
PLATE AMBI 135DEG 5HL 124136
|
Facility
|
IP
|
$3,967.00
|
|
| Hospital Charge Code |
2966023
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,021.58 |
| Max. Negotiated Rate |
$3,795.63 |
| Rate for Payer: Aetna Commercial |
$3,713.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,548.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,186.61
|
| Rate for Payer: Cash Price |
$1,190.10
|
| Rate for Payer: Cigna Commercial |
$3,795.63
|
| Rate for Payer: Health EOS Commercial |
$3,671.86
|
| Rate for Payer: HFN Commercial |
$3,795.63
|
| Rate for Payer: Multiplan Commercial |
$3,300.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,795.63
|
| Rate for Payer: Quartz Beloit One Network |
$2,021.58
|
| Rate for Payer: Quartz Commercial |
$2,475.41
|
| Rate for Payer: WEA Trust Commercial |
$2,269.12
|
| Rate for Payer: WPS Commercial |
$3,055.78
|
|
|
PLATE AMBI 135DEG 5HL 124136
|
Facility
|
OP
|
$3,967.00
|
|
| Hospital Charge Code |
2966023
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.19 |
| Max. Negotiated Rate |
$3,795.63 |
| Rate for Payer: Aetna Commercial |
$3,713.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,548.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,155.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,681.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,062.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,980.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,186.61
|
| Rate for Payer: Cash Price |
$1,190.10
|
| Rate for Payer: Cigna Commercial |
$3,795.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,308.79
|
| Rate for Payer: Health EOS Commercial |
$3,671.86
|
| Rate for Payer: HFN Commercial |
$3,795.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,094.26
|
| Rate for Payer: Multiplan Commercial |
$3,300.54
|
| Rate for Payer: NAPHCARE Commercial |
$2,475.41
|
| Rate for Payer: Preferred Network Access Commercial |
$3,795.63
|
| Rate for Payer: Quartz Beloit One Network |
$2,021.58
|
| Rate for Payer: Quartz Commercial |
$2,681.69
|
| Rate for Payer: Quartz Medicare Advantage |
$2,475.41
|
| Rate for Payer: The Alliance Commercial |
$2,062.84
|
| Rate for Payer: WEA Trust Commercial |
$2,269.12
|
| Rate for Payer: WPS Commercial |
$3,055.78
|
|
|
PLATE AMBI 135DEG 6HL 124141
|
Facility
|
IP
|
$4,103.00
|
|
| Hospital Charge Code |
2966024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,090.89 |
| Max. Negotiated Rate |
$3,925.75 |
| Rate for Payer: Aetna Commercial |
$3,840.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,669.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,261.57
|
| Rate for Payer: Cash Price |
$1,230.90
|
| Rate for Payer: Cigna Commercial |
$3,925.75
|
| Rate for Payer: Health EOS Commercial |
$3,797.74
|
| Rate for Payer: HFN Commercial |
$3,925.75
|
| Rate for Payer: Multiplan Commercial |
$3,413.70
|
| Rate for Payer: Preferred Network Access Commercial |
$3,925.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,090.89
|
| Rate for Payer: Quartz Commercial |
$2,560.27
|
| Rate for Payer: WEA Trust Commercial |
$2,346.92
|
| Rate for Payer: WPS Commercial |
$3,160.54
|
|
|
PLATE AMBI 135DEG 6HL 124141
|
Facility
|
OP
|
$4,103.00
|
|
| Hospital Charge Code |
2966024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.79 |
| Max. Negotiated Rate |
$3,925.75 |
| Rate for Payer: Aetna Commercial |
$3,840.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,669.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,194.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,773.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,133.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,048.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,261.57
|
| Rate for Payer: Cash Price |
$1,230.90
|
| Rate for Payer: Cigna Commercial |
$3,925.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,387.95
|
| Rate for Payer: Health EOS Commercial |
$3,797.74
|
| Rate for Payer: HFN Commercial |
$3,925.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,200.34
|
| Rate for Payer: Multiplan Commercial |
$3,413.70
|
| Rate for Payer: NAPHCARE Commercial |
$2,560.27
|
| Rate for Payer: Preferred Network Access Commercial |
$3,925.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,090.89
|
| Rate for Payer: Quartz Commercial |
$2,773.63
|
| Rate for Payer: Quartz Medicare Advantage |
$2,560.27
|
| Rate for Payer: The Alliance Commercial |
$2,133.56
|
| Rate for Payer: WEA Trust Commercial |
$2,346.92
|
| Rate for Payer: WPS Commercial |
$3,160.54
|
|
|
PLATE AMBI 135DEG 8HL 124146
|
Facility
|
IP
|
$3,747.00
|
|
| Hospital Charge Code |
2966032
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,909.47 |
| Max. Negotiated Rate |
$3,585.13 |
| Rate for Payer: Aetna Commercial |
$3,507.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,351.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,065.35
|
| Rate for Payer: Cash Price |
$1,124.10
|
| Rate for Payer: Cigna Commercial |
$3,585.13
|
| Rate for Payer: Health EOS Commercial |
$3,468.22
|
| Rate for Payer: HFN Commercial |
$3,585.13
|
| Rate for Payer: Multiplan Commercial |
$3,117.50
|
| Rate for Payer: Preferred Network Access Commercial |
$3,585.13
|
| Rate for Payer: Quartz Beloit One Network |
$1,909.47
|
| Rate for Payer: Quartz Commercial |
$2,338.13
|
| Rate for Payer: WEA Trust Commercial |
$2,143.28
|
| Rate for Payer: WPS Commercial |
$2,886.31
|
|
|
PLATE AMBI 135DEG 8HL 124146
|
Facility
|
OP
|
$3,747.00
|
|
| Hospital Charge Code |
2966032
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,091.13 |
| Max. Negotiated Rate |
$3,585.13 |
| Rate for Payer: Aetna Commercial |
$3,507.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,351.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,091.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,532.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,948.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,870.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,065.35
|
| Rate for Payer: Cash Price |
$1,124.10
|
| Rate for Payer: Cigna Commercial |
$3,585.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,180.75
|
| Rate for Payer: Health EOS Commercial |
$3,468.22
|
| Rate for Payer: HFN Commercial |
$3,585.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,922.66
|
| Rate for Payer: Multiplan Commercial |
$3,117.50
|
| Rate for Payer: NAPHCARE Commercial |
$2,338.13
|
| Rate for Payer: Preferred Network Access Commercial |
$3,585.13
|
| Rate for Payer: Quartz Beloit One Network |
$1,909.47
|
| Rate for Payer: Quartz Commercial |
$2,532.97
|
| Rate for Payer: Quartz Medicare Advantage |
$2,338.13
|
| Rate for Payer: The Alliance Commercial |
$1,948.44
|
| Rate for Payer: WEA Trust Commercial |
$2,143.28
|
| Rate for Payer: WPS Commercial |
$2,886.31
|
|
|
PLATE AMBI 140DEG 4HL 124132
|
Facility
|
IP
|
$3,580.00
|
|
| Hospital Charge Code |
2966025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.37 |
| Max. Negotiated Rate |
$3,425.34 |
| Rate for Payer: Aetna Commercial |
$3,350.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,201.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,973.30
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cigna Commercial |
$3,425.34
|
| Rate for Payer: Health EOS Commercial |
$3,313.65
|
| Rate for Payer: HFN Commercial |
$3,425.34
|
| Rate for Payer: Multiplan Commercial |
$2,978.56
|
| Rate for Payer: Preferred Network Access Commercial |
$3,425.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,824.37
|
| Rate for Payer: Quartz Commercial |
$2,233.92
|
| Rate for Payer: WEA Trust Commercial |
$2,047.76
|
| Rate for Payer: WPS Commercial |
$2,757.67
|
|
|
PLATE AMBI 140DEG 4HL 124132
|
Facility
|
OP
|
$3,580.00
|
|
| Hospital Charge Code |
2966025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.50 |
| Max. Negotiated Rate |
$3,425.34 |
| Rate for Payer: Aetna Commercial |
$3,350.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,201.95
|
| Rate for Payer: Aetna Managed Medicare |
$1,042.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,420.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,861.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,787.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,973.30
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cigna Commercial |
$3,425.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,083.56
|
| Rate for Payer: Health EOS Commercial |
$3,313.65
|
| Rate for Payer: HFN Commercial |
$3,425.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,792.40
|
| Rate for Payer: Multiplan Commercial |
$2,978.56
|
| Rate for Payer: NAPHCARE Commercial |
$2,233.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,425.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,824.37
|
| Rate for Payer: Quartz Commercial |
$2,420.08
|
| Rate for Payer: Quartz Medicare Advantage |
$2,233.92
|
| Rate for Payer: The Alliance Commercial |
$1,861.60
|
| Rate for Payer: WEA Trust Commercial |
$2,047.76
|
| Rate for Payer: WPS Commercial |
$2,757.67
|
|
|
PLATE AMBI 140DEG 5HL 124137
|
Facility
|
IP
|
$3,447.00
|
|
| Hospital Charge Code |
2966026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,756.59 |
| Max. Negotiated Rate |
$3,298.09 |
| Rate for Payer: Aetna Commercial |
$3,226.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,083.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,899.99
|
| Rate for Payer: Cash Price |
$1,034.10
|
| Rate for Payer: Cigna Commercial |
$3,298.09
|
| Rate for Payer: Health EOS Commercial |
$3,190.54
|
| Rate for Payer: HFN Commercial |
$3,298.09
|
| Rate for Payer: Multiplan Commercial |
$2,867.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,298.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,756.59
|
| Rate for Payer: Quartz Commercial |
$2,150.93
|
| Rate for Payer: WEA Trust Commercial |
$1,971.68
|
| Rate for Payer: WPS Commercial |
$2,655.22
|
|
|
PLATE AMBI 140DEG 5HL 124137
|
Facility
|
OP
|
$3,447.00
|
|
| Hospital Charge Code |
2966026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.77 |
| Max. Negotiated Rate |
$3,298.09 |
| Rate for Payer: Aetna Commercial |
$3,226.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,083.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,003.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,330.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,792.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,720.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,899.99
|
| Rate for Payer: Cash Price |
$1,034.10
|
| Rate for Payer: Cigna Commercial |
$3,298.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,006.15
|
| Rate for Payer: Health EOS Commercial |
$3,190.54
|
| Rate for Payer: HFN Commercial |
$3,298.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,688.66
|
| Rate for Payer: Multiplan Commercial |
$2,867.90
|
| Rate for Payer: NAPHCARE Commercial |
$2,150.93
|
| Rate for Payer: Preferred Network Access Commercial |
$3,298.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,756.59
|
| Rate for Payer: Quartz Commercial |
$2,330.17
|
| Rate for Payer: Quartz Medicare Advantage |
$2,150.93
|
| Rate for Payer: The Alliance Commercial |
$1,792.44
|
| Rate for Payer: WEA Trust Commercial |
$1,971.68
|
| Rate for Payer: WPS Commercial |
$2,655.22
|
|
|
PLATE AMBI 145DEG 6HL 124143
|
Facility
|
IP
|
$3,447.00
|
|
| Hospital Charge Code |
2966027
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,756.59 |
| Max. Negotiated Rate |
$3,298.09 |
| Rate for Payer: Aetna Commercial |
$3,226.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,083.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,899.99
|
| Rate for Payer: Cash Price |
$1,034.10
|
| Rate for Payer: Cigna Commercial |
$3,298.09
|
| Rate for Payer: Health EOS Commercial |
$3,190.54
|
| Rate for Payer: HFN Commercial |
$3,298.09
|
| Rate for Payer: Multiplan Commercial |
$2,867.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,298.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,756.59
|
| Rate for Payer: Quartz Commercial |
$2,150.93
|
| Rate for Payer: WEA Trust Commercial |
$1,971.68
|
| Rate for Payer: WPS Commercial |
$2,655.22
|
|
|
PLATE AMBI 145DEG 6HL 124143
|
Facility
|
OP
|
$3,447.00
|
|
| Hospital Charge Code |
2966027
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.77 |
| Max. Negotiated Rate |
$3,298.09 |
| Rate for Payer: Aetna Commercial |
$3,226.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,083.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,003.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,330.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,792.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,720.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,899.99
|
| Rate for Payer: Cash Price |
$1,034.10
|
| Rate for Payer: Cigna Commercial |
$3,298.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,006.15
|
| Rate for Payer: Health EOS Commercial |
$3,190.54
|
| Rate for Payer: HFN Commercial |
$3,298.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,688.66
|
| Rate for Payer: Multiplan Commercial |
$2,867.90
|
| Rate for Payer: NAPHCARE Commercial |
$2,150.93
|
| Rate for Payer: Preferred Network Access Commercial |
$3,298.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,756.59
|
| Rate for Payer: Quartz Commercial |
$2,330.17
|
| Rate for Payer: Quartz Medicare Advantage |
$2,150.93
|
| Rate for Payer: The Alliance Commercial |
$1,792.44
|
| Rate for Payer: WEA Trust Commercial |
$1,971.68
|
| Rate for Payer: WPS Commercial |
$2,655.22
|
|
|
PLATE AMBI 150DEG 5HL 124139
|
Facility
|
OP
|
$3,072.00
|
|
| Hospital Charge Code |
2966028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$894.57 |
| Max. Negotiated Rate |
$2,939.29 |
| Rate for Payer: Aetna Commercial |
$2,875.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,747.60
|
| Rate for Payer: Aetna Managed Medicare |
$894.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,076.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,597.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,533.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,693.29
|
| Rate for Payer: Cash Price |
$921.60
|
| Rate for Payer: Cigna Commercial |
$2,939.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,787.90
|
| Rate for Payer: Health EOS Commercial |
$2,843.44
|
| Rate for Payer: HFN Commercial |
$2,939.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,396.16
|
| Rate for Payer: Multiplan Commercial |
$2,555.90
|
| Rate for Payer: NAPHCARE Commercial |
$1,916.93
|
| Rate for Payer: Preferred Network Access Commercial |
$2,939.29
|
| Rate for Payer: Quartz Beloit One Network |
$1,565.49
|
| Rate for Payer: Quartz Commercial |
$2,076.67
|
| Rate for Payer: Quartz Medicare Advantage |
$1,916.93
|
| Rate for Payer: The Alliance Commercial |
$1,597.44
|
| Rate for Payer: WEA Trust Commercial |
$1,757.18
|
| Rate for Payer: WPS Commercial |
$2,366.36
|
|
|
PLATE AMBI 150DEG 5HL 124139
|
Facility
|
IP
|
$3,072.00
|
|
| Hospital Charge Code |
2966028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.49 |
| Max. Negotiated Rate |
$2,939.29 |
| Rate for Payer: Aetna Commercial |
$2,875.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,747.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,693.29
|
| Rate for Payer: Cash Price |
$921.60
|
| Rate for Payer: Cigna Commercial |
$2,939.29
|
| Rate for Payer: Health EOS Commercial |
$2,843.44
|
| Rate for Payer: HFN Commercial |
$2,939.29
|
| Rate for Payer: Multiplan Commercial |
$2,555.90
|
| Rate for Payer: Preferred Network Access Commercial |
$2,939.29
|
| Rate for Payer: Quartz Beloit One Network |
$1,565.49
|
| Rate for Payer: Quartz Commercial |
$1,916.93
|
| Rate for Payer: WEA Trust Commercial |
$1,757.18
|
| Rate for Payer: WPS Commercial |
$2,366.36
|
|
|
PLATE AMBI SUPRACON 90DEG 8HL 124170
|
Facility
|
OP
|
$3,119.00
|
|
| Hospital Charge Code |
2966033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$908.25 |
| Max. Negotiated Rate |
$2,984.26 |
| Rate for Payer: Aetna Commercial |
$2,919.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,789.63
|
| Rate for Payer: Aetna Managed Medicare |
$908.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,108.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,621.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,557.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,719.19
|
| Rate for Payer: Cash Price |
$935.70
|
| Rate for Payer: Cigna Commercial |
$2,984.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,815.26
|
| Rate for Payer: Health EOS Commercial |
$2,886.95
|
| Rate for Payer: HFN Commercial |
$2,984.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,432.82
|
| Rate for Payer: Multiplan Commercial |
$2,595.01
|
| Rate for Payer: NAPHCARE Commercial |
$1,946.26
|
| Rate for Payer: Preferred Network Access Commercial |
$2,984.26
|
| Rate for Payer: Quartz Beloit One Network |
$1,589.44
|
| Rate for Payer: Quartz Commercial |
$2,108.44
|
| Rate for Payer: Quartz Medicare Advantage |
$1,946.26
|
| Rate for Payer: The Alliance Commercial |
$1,621.88
|
| Rate for Payer: WEA Trust Commercial |
$1,784.07
|
| Rate for Payer: WPS Commercial |
$2,402.57
|
|
|
PLATE AMBI SUPRACON 90DEG 8HL 124170
|
Facility
|
IP
|
$3,119.00
|
|
| Hospital Charge Code |
2966033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,589.44 |
| Max. Negotiated Rate |
$2,984.26 |
| Rate for Payer: Aetna Commercial |
$2,919.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,789.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,719.19
|
| Rate for Payer: Cash Price |
$935.70
|
| Rate for Payer: Cigna Commercial |
$2,984.26
|
| Rate for Payer: Health EOS Commercial |
$2,886.95
|
| Rate for Payer: HFN Commercial |
$2,984.26
|
| Rate for Payer: Multiplan Commercial |
$2,595.01
|
| Rate for Payer: Preferred Network Access Commercial |
$2,984.26
|
| Rate for Payer: Quartz Beloit One Network |
$1,589.44
|
| Rate for Payer: Quartz Commercial |
$1,946.26
|
| Rate for Payer: WEA Trust Commercial |
$1,784.07
|
| Rate for Payer: WPS Commercial |
$2,402.57
|
|
|
PLATE ANCHORAGE MTP CP LEFT PLP14341
|
Facility
|
OP
|
$7,316.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5265002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,130.42 |
| Max. Negotiated Rate |
$6,999.95 |
| Rate for Payer: Aetna Commercial |
$6,847.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,543.43
|
| Rate for Payer: Aetna Managed Medicare |
$2,130.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,945.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,804.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,652.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,032.58
|
| Rate for Payer: Cash Price |
$2,194.80
|
| Rate for Payer: Cigna Commercial |
$6,999.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,257.91
|
| Rate for Payer: Health EOS Commercial |
$6,771.69
|
| Rate for Payer: HFN Commercial |
$6,999.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,706.48
|
| Rate for Payer: Multiplan Commercial |
$6,086.91
|
| Rate for Payer: NAPHCARE Commercial |
$4,565.18
|
| Rate for Payer: Preferred Network Access Commercial |
$6,999.95
|
| Rate for Payer: Quartz Beloit One Network |
$3,728.23
|
| Rate for Payer: Quartz Commercial |
$4,945.62
|
| Rate for Payer: Quartz Medicare Advantage |
$4,565.18
|
| Rate for Payer: The Alliance Commercial |
$3,804.32
|
| Rate for Payer: WEA Trust Commercial |
$4,184.75
|
| Rate for Payer: WPS Commercial |
$5,635.51
|
|
|
PLATE ANCHORAGE MTP CP LEFT PLP14341
|
Facility
|
IP
|
$7,316.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5265002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,728.23 |
| Max. Negotiated Rate |
$6,999.95 |
| Rate for Payer: Aetna Commercial |
$6,847.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,543.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,032.58
|
| Rate for Payer: Cash Price |
$2,194.80
|
| Rate for Payer: Cigna Commercial |
$6,999.95
|
| Rate for Payer: Health EOS Commercial |
$6,771.69
|
| Rate for Payer: HFN Commercial |
$6,999.95
|
| Rate for Payer: Multiplan Commercial |
$6,086.91
|
| Rate for Payer: Preferred Network Access Commercial |
$6,999.95
|
| Rate for Payer: Quartz Beloit One Network |
$3,728.23
|
| Rate for Payer: Quartz Commercial |
$4,565.18
|
| Rate for Payer: WEA Trust Commercial |
$4,184.75
|
| Rate for Payer: WPS Commercial |
$5,635.51
|
|
|
PLATE ANCHORAGE MTP V1 LONG LT 6HL PLP10341
|
Facility
|
OP
|
$9,271.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,699.72 |
| Max. Negotiated Rate |
$8,870.49 |
| Rate for Payer: Aetna Commercial |
$8,677.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,291.98
|
| Rate for Payer: Aetna Managed Medicare |
$2,699.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,267.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,820.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,628.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,110.18
|
| Rate for Payer: Cash Price |
$2,781.30
|
| Rate for Payer: Cigna Commercial |
$8,870.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,395.72
|
| Rate for Payer: Health EOS Commercial |
$8,581.24
|
| Rate for Payer: HFN Commercial |
$8,870.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,231.38
|
| Rate for Payer: Multiplan Commercial |
$7,713.47
|
| Rate for Payer: NAPHCARE Commercial |
$5,785.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,870.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,724.50
|
| Rate for Payer: Quartz Commercial |
$6,267.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,785.10
|
| Rate for Payer: The Alliance Commercial |
$4,820.92
|
| Rate for Payer: WEA Trust Commercial |
$5,303.01
|
| Rate for Payer: WPS Commercial |
$7,141.45
|
|
