|
PLATE 1.5 6HL CONDYLAR SYNTHES
|
Facility
|
OP
|
$5,227.00
|
|
| Hospital Charge Code |
2966310
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,522.10 |
| Max. Negotiated Rate |
$5,001.19 |
| Rate for Payer: Aetna Commercial |
$4,892.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,675.03
|
| Rate for Payer: Aetna Managed Medicare |
$1,522.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,533.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,718.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,609.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,881.12
|
| Rate for Payer: Cash Price |
$1,568.10
|
| Rate for Payer: Cigna Commercial |
$5,001.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,042.11
|
| Rate for Payer: Health EOS Commercial |
$4,838.11
|
| Rate for Payer: HFN Commercial |
$5,001.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,077.06
|
| Rate for Payer: Multiplan Commercial |
$4,348.86
|
| Rate for Payer: NAPHCARE Commercial |
$3,261.65
|
| Rate for Payer: Preferred Network Access Commercial |
$5,001.19
|
| Rate for Payer: Quartz Beloit One Network |
$2,663.68
|
| Rate for Payer: Quartz Commercial |
$3,533.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,261.65
|
| Rate for Payer: The Alliance Commercial |
$2,718.04
|
| Rate for Payer: WEA Trust Commercial |
$2,989.84
|
| Rate for Payer: WPS Commercial |
$4,026.36
|
|
|
PLATE 1.5 6HL CONDYLAR SYNTHES
|
Facility
|
IP
|
$5,227.00
|
|
| Hospital Charge Code |
2966310
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,663.68 |
| Max. Negotiated Rate |
$5,001.19 |
| Rate for Payer: Aetna Commercial |
$4,892.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,675.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,881.12
|
| Rate for Payer: Cash Price |
$1,568.10
|
| Rate for Payer: Cigna Commercial |
$5,001.19
|
| Rate for Payer: Health EOS Commercial |
$4,838.11
|
| Rate for Payer: HFN Commercial |
$5,001.19
|
| Rate for Payer: Multiplan Commercial |
$4,348.86
|
| Rate for Payer: Preferred Network Access Commercial |
$5,001.19
|
| Rate for Payer: Quartz Beloit One Network |
$2,663.68
|
| Rate for Payer: Quartz Commercial |
$3,261.65
|
| Rate for Payer: WEA Trust Commercial |
$2,989.84
|
| Rate for Payer: WPS Commercial |
$4,026.36
|
|
|
PLATE 1.5 EXT H-PLATE RT
|
Facility
|
IP
|
$5,051.00
|
|
| Hospital Charge Code |
2966311
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,573.99 |
| Max. Negotiated Rate |
$4,832.80 |
| Rate for Payer: Aetna Commercial |
$4,727.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,517.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,784.11
|
| Rate for Payer: Cash Price |
$1,515.30
|
| Rate for Payer: Cigna Commercial |
$4,832.80
|
| Rate for Payer: Health EOS Commercial |
$4,675.21
|
| Rate for Payer: HFN Commercial |
$4,832.80
|
| Rate for Payer: Multiplan Commercial |
$4,202.43
|
| Rate for Payer: Preferred Network Access Commercial |
$4,832.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,573.99
|
| Rate for Payer: Quartz Commercial |
$3,151.82
|
| Rate for Payer: WEA Trust Commercial |
$2,889.17
|
| Rate for Payer: WPS Commercial |
$3,890.79
|
|
|
PLATE 1.5 EXT H-PLATE RT
|
Facility
|
OP
|
$5,051.00
|
|
| Hospital Charge Code |
2966311
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,470.85 |
| Max. Negotiated Rate |
$4,832.80 |
| Rate for Payer: Aetna Commercial |
$4,727.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,517.61
|
| Rate for Payer: Aetna Managed Medicare |
$1,470.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,414.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,626.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,521.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,784.11
|
| Rate for Payer: Cash Price |
$1,515.30
|
| Rate for Payer: Cigna Commercial |
$4,832.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,939.68
|
| Rate for Payer: Health EOS Commercial |
$4,675.21
|
| Rate for Payer: HFN Commercial |
$4,832.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,939.78
|
| Rate for Payer: Multiplan Commercial |
$4,202.43
|
| Rate for Payer: NAPHCARE Commercial |
$3,151.82
|
| Rate for Payer: Preferred Network Access Commercial |
$4,832.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,573.99
|
| Rate for Payer: Quartz Commercial |
$3,414.48
|
| Rate for Payer: Quartz Medicare Advantage |
$3,151.82
|
| Rate for Payer: The Alliance Commercial |
$2,626.52
|
| Rate for Payer: WEA Trust Commercial |
$2,889.17
|
| Rate for Payer: WPS Commercial |
$3,890.79
|
|
|
PLATE 1.5 LCP ADAPTION 6HOLES 02.114.503
|
Facility
|
OP
|
$5,809.00
|
|
| Hospital Charge Code |
2966312
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,691.58 |
| Max. Negotiated Rate |
$5,558.05 |
| Rate for Payer: Aetna Commercial |
$5,437.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,195.57
|
| Rate for Payer: Aetna Managed Medicare |
$1,691.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,926.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,020.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,899.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,201.92
|
| Rate for Payer: Cash Price |
$1,742.70
|
| Rate for Payer: Cigna Commercial |
$5,558.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,380.84
|
| Rate for Payer: Health EOS Commercial |
$5,376.81
|
| Rate for Payer: HFN Commercial |
$5,558.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,531.02
|
| Rate for Payer: Multiplan Commercial |
$4,833.09
|
| Rate for Payer: NAPHCARE Commercial |
$3,624.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,558.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,960.27
|
| Rate for Payer: Quartz Commercial |
$3,926.88
|
| Rate for Payer: Quartz Medicare Advantage |
$3,624.82
|
| Rate for Payer: The Alliance Commercial |
$3,020.68
|
| Rate for Payer: WEA Trust Commercial |
$3,322.75
|
| Rate for Payer: WPS Commercial |
$4,474.67
|
|
|
PLATE 1.5 LCP ADAPTION 6HOLES 02.114.503
|
Facility
|
IP
|
$5,809.00
|
|
| Hospital Charge Code |
2966312
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,960.27 |
| Max. Negotiated Rate |
$5,558.05 |
| Rate for Payer: Aetna Commercial |
$5,437.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,195.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,201.92
|
| Rate for Payer: Cash Price |
$1,742.70
|
| Rate for Payer: Cigna Commercial |
$5,558.05
|
| Rate for Payer: Health EOS Commercial |
$5,376.81
|
| Rate for Payer: HFN Commercial |
$5,558.05
|
| Rate for Payer: Multiplan Commercial |
$4,833.09
|
| Rate for Payer: Preferred Network Access Commercial |
$5,558.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,960.27
|
| Rate for Payer: Quartz Commercial |
$3,624.82
|
| Rate for Payer: WEA Trust Commercial |
$3,322.75
|
| Rate for Payer: WPS Commercial |
$4,474.67
|
|
|
PLATE 1.5 LCP CONDYLAR 6H 02.114.514
|
Facility
|
IP
|
$5,208.00
|
|
| Hospital Charge Code |
2966313
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,654.00 |
| Max. Negotiated Rate |
$4,983.01 |
| Rate for Payer: Aetna Commercial |
$4,874.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,658.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,870.65
|
| Rate for Payer: Cash Price |
$1,562.40
|
| Rate for Payer: Cigna Commercial |
$4,983.01
|
| Rate for Payer: Health EOS Commercial |
$4,820.52
|
| Rate for Payer: HFN Commercial |
$4,983.01
|
| Rate for Payer: Multiplan Commercial |
$4,333.06
|
| Rate for Payer: Preferred Network Access Commercial |
$4,983.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,654.00
|
| Rate for Payer: Quartz Commercial |
$3,249.79
|
| Rate for Payer: WEA Trust Commercial |
$2,978.98
|
| Rate for Payer: WPS Commercial |
$4,011.72
|
|
|
PLATE 1.5 LCP CONDYLAR 6H 02.114.514
|
Facility
|
OP
|
$5,208.00
|
|
| Hospital Charge Code |
2966313
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,516.57 |
| Max. Negotiated Rate |
$4,983.01 |
| Rate for Payer: Aetna Commercial |
$4,874.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,658.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,516.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,520.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,708.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,599.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,870.65
|
| Rate for Payer: Cash Price |
$1,562.40
|
| Rate for Payer: Cigna Commercial |
$4,983.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,031.06
|
| Rate for Payer: Health EOS Commercial |
$4,820.52
|
| Rate for Payer: HFN Commercial |
$4,983.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,062.24
|
| Rate for Payer: Multiplan Commercial |
$4,333.06
|
| Rate for Payer: NAPHCARE Commercial |
$3,249.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,983.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,654.00
|
| Rate for Payer: Quartz Commercial |
$3,520.61
|
| Rate for Payer: Quartz Medicare Advantage |
$3,249.79
|
| Rate for Payer: The Alliance Commercial |
$2,708.16
|
| Rate for Payer: WEA Trust Commercial |
$2,978.98
|
| Rate for Payer: WPS Commercial |
$4,011.72
|
|
|
PLATE 1.5MM 6HL ADAPTION
|
Facility
|
IP
|
$5,917.00
|
|
| Hospital Charge Code |
2966315
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,015.30 |
| Max. Negotiated Rate |
$5,661.39 |
| Rate for Payer: Aetna Commercial |
$5,538.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,292.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,261.45
|
| Rate for Payer: Cash Price |
$1,775.10
|
| Rate for Payer: Cigna Commercial |
$5,661.39
|
| Rate for Payer: Health EOS Commercial |
$5,476.78
|
| Rate for Payer: HFN Commercial |
$5,661.39
|
| Rate for Payer: Multiplan Commercial |
$4,922.94
|
| Rate for Payer: Preferred Network Access Commercial |
$5,661.39
|
| Rate for Payer: Quartz Beloit One Network |
$3,015.30
|
| Rate for Payer: Quartz Commercial |
$3,692.21
|
| Rate for Payer: WEA Trust Commercial |
$3,384.52
|
| Rate for Payer: WPS Commercial |
$4,557.87
|
|
|
PLATE 1.5MM 6HL ADAPTION
|
Facility
|
OP
|
$5,917.00
|
|
| Hospital Charge Code |
2966315
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,723.03 |
| Max. Negotiated Rate |
$5,661.39 |
| Rate for Payer: Aetna Commercial |
$5,538.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,292.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,723.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,999.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,076.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,953.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,261.45
|
| Rate for Payer: Cash Price |
$1,775.10
|
| Rate for Payer: Cigna Commercial |
$5,661.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,443.69
|
| Rate for Payer: Health EOS Commercial |
$5,476.78
|
| Rate for Payer: HFN Commercial |
$5,661.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,615.26
|
| Rate for Payer: Multiplan Commercial |
$4,922.94
|
| Rate for Payer: NAPHCARE Commercial |
$3,692.21
|
| Rate for Payer: Preferred Network Access Commercial |
$5,661.39
|
| Rate for Payer: Quartz Beloit One Network |
$3,015.30
|
| Rate for Payer: Quartz Commercial |
$3,999.89
|
| Rate for Payer: Quartz Medicare Advantage |
$3,692.21
|
| Rate for Payer: The Alliance Commercial |
$3,076.84
|
| Rate for Payer: WEA Trust Commercial |
$3,384.52
|
| Rate for Payer: WPS Commercial |
$4,557.87
|
|
|
PLATE 1.5 T 421.333
|
Facility
|
IP
|
$2,775.00
|
|
| Hospital Charge Code |
2966314
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,414.14 |
| Max. Negotiated Rate |
$2,655.12 |
| Rate for Payer: Aetna Commercial |
$2,597.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,481.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,529.58
|
| Rate for Payer: Cash Price |
$832.50
|
| Rate for Payer: Cigna Commercial |
$2,655.12
|
| Rate for Payer: Health EOS Commercial |
$2,568.54
|
| Rate for Payer: HFN Commercial |
$2,655.12
|
| Rate for Payer: Multiplan Commercial |
$2,308.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,655.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,414.14
|
| Rate for Payer: Quartz Commercial |
$1,731.60
|
| Rate for Payer: WEA Trust Commercial |
$1,587.30
|
| Rate for Payer: WPS Commercial |
$2,137.58
|
|
|
PLATE 1.5 T 421.333
|
Facility
|
OP
|
$2,775.00
|
|
| Hospital Charge Code |
2966314
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$808.08 |
| Max. Negotiated Rate |
$2,655.12 |
| Rate for Payer: Aetna Commercial |
$2,597.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,481.96
|
| Rate for Payer: Aetna Managed Medicare |
$808.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,875.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,443.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,385.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,529.58
|
| Rate for Payer: Cash Price |
$832.50
|
| Rate for Payer: Cigna Commercial |
$2,655.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,615.05
|
| Rate for Payer: Health EOS Commercial |
$2,568.54
|
| Rate for Payer: HFN Commercial |
$2,655.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,164.50
|
| Rate for Payer: Multiplan Commercial |
$2,308.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,731.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,655.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,414.14
|
| Rate for Payer: Quartz Commercial |
$1,875.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,731.60
|
| Rate for Payer: The Alliance Commercial |
$1,443.00
|
| Rate for Payer: WEA Trust Commercial |
$1,587.30
|
| Rate for Payer: WPS Commercial |
$2,137.58
|
|
|
PLATE 2.0MM LCP DISTAL ULNA 7HL 242.531S
|
Facility
|
OP
|
$8,104.00
|
|
| Hospital Charge Code |
2966321
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.88 |
| Max. Negotiated Rate |
$7,753.91 |
| Rate for Payer: Aetna Commercial |
$7,585.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,248.22
|
| Rate for Payer: Aetna Managed Medicare |
$2,359.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,478.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,214.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,045.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,466.92
|
| Rate for Payer: Cash Price |
$2,431.20
|
| Rate for Payer: Cigna Commercial |
$7,753.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,716.53
|
| Rate for Payer: Health EOS Commercial |
$7,501.06
|
| Rate for Payer: HFN Commercial |
$7,753.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,321.12
|
| Rate for Payer: Multiplan Commercial |
$6,742.53
|
| Rate for Payer: NAPHCARE Commercial |
$5,056.90
|
| Rate for Payer: Preferred Network Access Commercial |
$7,753.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,129.80
|
| Rate for Payer: Quartz Commercial |
$5,478.30
|
| Rate for Payer: Quartz Medicare Advantage |
$5,056.90
|
| Rate for Payer: The Alliance Commercial |
$4,214.08
|
| Rate for Payer: WEA Trust Commercial |
$4,635.49
|
| Rate for Payer: WPS Commercial |
$6,242.51
|
|
|
PLATE 2.0MM LCP DISTAL ULNA 7HL 242.531S
|
Facility
|
IP
|
$8,104.00
|
|
| Hospital Charge Code |
2966321
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,129.80 |
| Max. Negotiated Rate |
$7,753.91 |
| Rate for Payer: Aetna Commercial |
$7,585.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,248.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,466.92
|
| Rate for Payer: Cash Price |
$2,431.20
|
| Rate for Payer: Cigna Commercial |
$7,753.91
|
| Rate for Payer: Health EOS Commercial |
$7,501.06
|
| Rate for Payer: HFN Commercial |
$7,753.91
|
| Rate for Payer: Multiplan Commercial |
$6,742.53
|
| Rate for Payer: Preferred Network Access Commercial |
$7,753.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,129.80
|
| Rate for Payer: Quartz Commercial |
$5,056.90
|
| Rate for Payer: WEA Trust Commercial |
$4,635.49
|
| Rate for Payer: WPS Commercial |
$6,242.51
|
|
|
PLATE 2.0 STRAIGHT 12 HL VA 02.130.351S
|
Facility
|
OP
|
$5,408.00
|
|
| Hospital Charge Code |
4858884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,574.81 |
| Max. Negotiated Rate |
$5,174.37 |
| Rate for Payer: Aetna Commercial |
$5,061.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,836.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,574.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,655.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,812.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,699.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,980.89
|
| Rate for Payer: Cash Price |
$1,622.40
|
| Rate for Payer: Cigna Commercial |
$5,174.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,147.46
|
| Rate for Payer: Health EOS Commercial |
$5,005.64
|
| Rate for Payer: HFN Commercial |
$5,174.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,218.24
|
| Rate for Payer: Multiplan Commercial |
$4,499.46
|
| Rate for Payer: NAPHCARE Commercial |
$3,374.59
|
| Rate for Payer: Preferred Network Access Commercial |
$5,174.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,755.92
|
| Rate for Payer: Quartz Commercial |
$3,655.81
|
| Rate for Payer: Quartz Medicare Advantage |
$3,374.59
|
| Rate for Payer: The Alliance Commercial |
$2,812.16
|
| Rate for Payer: WEA Trust Commercial |
$3,093.38
|
| Rate for Payer: WPS Commercial |
$4,165.78
|
|
|
PLATE 2.0 STRAIGHT 12 HL VA 02.130.351S
|
Facility
|
IP
|
$5,408.00
|
|
| Hospital Charge Code |
4858884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,755.92 |
| Max. Negotiated Rate |
$5,174.37 |
| Rate for Payer: Aetna Commercial |
$5,061.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,836.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,980.89
|
| Rate for Payer: Cash Price |
$1,622.40
|
| Rate for Payer: Cigna Commercial |
$5,174.37
|
| Rate for Payer: Health EOS Commercial |
$5,005.64
|
| Rate for Payer: HFN Commercial |
$5,174.37
|
| Rate for Payer: Multiplan Commercial |
$4,499.46
|
| Rate for Payer: Preferred Network Access Commercial |
$5,174.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,755.92
|
| Rate for Payer: Quartz Commercial |
$3,374.59
|
| Rate for Payer: WEA Trust Commercial |
$3,093.38
|
| Rate for Payer: WPS Commercial |
$4,165.78
|
|
|
PLATE 2.4 6HL/2H LT 04.111.621
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,815.92 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,815.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,215.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,242.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,113.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,629.35
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,864.08
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: NAPHCARE Commercial |
$3,891.26
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$4,215.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,891.26
|
| Rate for Payer: The Alliance Commercial |
$3,242.72
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 6HL/2H LT 04.111.621
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,177.87 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$3,891.26
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 6HL/2H RT 04.111.620
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,815.92 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,815.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,215.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,242.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,113.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,629.35
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,864.08
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: NAPHCARE Commercial |
$3,891.26
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$4,215.54
|
| Rate for Payer: Quartz Medicare Advantage |
$3,891.26
|
| Rate for Payer: The Alliance Commercial |
$3,242.72
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 6HL/2H RT 04.111.620
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,177.87 |
| Max. Negotiated Rate |
$5,966.60 |
| Rate for Payer: Aetna Commercial |
$5,836.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.28
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,966.60
|
| Rate for Payer: Health EOS Commercial |
$5,772.04
|
| Rate for Payer: HFN Commercial |
$5,966.60
|
| Rate for Payer: Multiplan Commercial |
$5,188.35
|
| Rate for Payer: Preferred Network Access Commercial |
$5,966.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.87
|
| Rate for Payer: Quartz Commercial |
$3,891.26
|
| Rate for Payer: WEA Trust Commercial |
$3,566.99
|
| Rate for Payer: WPS Commercial |
$4,803.59
|
|
|
PLATE 2.4 6HL/3H LT 04.111.631
|
Facility
|
IP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.67 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,203.26
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 6HL/3H LT 04.111.631
|
Facility
|
OP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.52 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,502.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.35
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.08
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,553.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.26
|
| Rate for Payer: The Alliance Commercial |
$3,502.72
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 6HL/3H RT 04.111.630
|
Facility
|
OP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.52 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,502.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.35
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.08
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,553.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.26
|
| Rate for Payer: The Alliance Commercial |
$3,502.72
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 6HL/3H RT 04.111.630
|
Facility
|
IP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.67 |
| Max. Negotiated Rate |
$6,445.00 |
| Rate for Payer: Aetna Commercial |
$6,304.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,024.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,712.88
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,445.00
|
| Rate for Payer: Health EOS Commercial |
$6,234.84
|
| Rate for Payer: HFN Commercial |
$6,445.00
|
| Rate for Payer: Multiplan Commercial |
$5,604.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.67
|
| Rate for Payer: Quartz Commercial |
$4,203.26
|
| Rate for Payer: WEA Trust Commercial |
$3,852.99
|
| Rate for Payer: WPS Commercial |
$5,188.74
|
|
|
PLATE 2.4 6HL/4H LT 04.111.641
|
Facility
|
OP
|
$6,987.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,034.61 |
| Max. Negotiated Rate |
$6,685.16 |
| Rate for Payer: Aetna Commercial |
$6,539.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,249.17
|
| Rate for Payer: Aetna Managed Medicare |
$2,034.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,723.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,633.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,487.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,851.23
|
| Rate for Payer: Cash Price |
$2,096.10
|
| Rate for Payer: Cigna Commercial |
$6,685.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,066.43
|
| Rate for Payer: Health EOS Commercial |
$6,467.17
|
| Rate for Payer: HFN Commercial |
$6,685.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,449.86
|
| Rate for Payer: Multiplan Commercial |
$5,813.18
|
| Rate for Payer: NAPHCARE Commercial |
$4,359.89
|
| Rate for Payer: Preferred Network Access Commercial |
$6,685.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,560.58
|
| Rate for Payer: Quartz Commercial |
$4,723.21
|
| Rate for Payer: Quartz Medicare Advantage |
$4,359.89
|
| Rate for Payer: The Alliance Commercial |
$3,633.24
|
| Rate for Payer: WEA Trust Commercial |
$3,996.56
|
| Rate for Payer: WPS Commercial |
$5,382.09
|
|
