|
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 |
$1,746.08 |
| Max. Negotiated Rate |
$24,944.00 |
| Rate for Payer: Aetna Commercial |
$5,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,746.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,053.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,993.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,305.08
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,737.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,489.67
|
| Rate for Payer: Health EOS Commercial |
$5,550.04
|
| Rate for Payer: HFN Commercial |
$5,737.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,677.00
|
| Rate for Payer: Multiplan Commercial |
$4,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.64
|
| Rate for Payer: Quartz Commercial |
$4,053.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,741.60
|
| Rate for Payer: The Alliance Commercial |
$24,944.00
|
| Rate for Payer: WEA Trust Commercial |
$3,429.80
|
| Rate for Payer: WPS Commercial |
$4,619.01
|
|
|
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 |
$1,746.08 |
| Max. Negotiated Rate |
$24,944.00 |
| Rate for Payer: Aetna Commercial |
$5,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,746.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,053.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,993.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,305.08
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,737.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,489.67
|
| Rate for Payer: Health EOS Commercial |
$5,550.04
|
| Rate for Payer: HFN Commercial |
$5,737.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,677.00
|
| Rate for Payer: Multiplan Commercial |
$4,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.64
|
| Rate for Payer: Quartz Commercial |
$4,053.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,741.60
|
| Rate for Payer: The Alliance Commercial |
$24,944.00
|
| Rate for Payer: WEA Trust Commercial |
$3,429.80
|
| Rate for Payer: WPS Commercial |
$4,619.01
|
|
|
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 |
$3,055.64 |
| Max. Negotiated Rate |
$5,737.12 |
| Rate for Payer: Aetna Commercial |
$5,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,305.08
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,737.12
|
| Rate for Payer: Health EOS Commercial |
$5,550.04
|
| Rate for Payer: HFN Commercial |
$5,737.12
|
| Rate for Payer: Multiplan Commercial |
$4,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.64
|
| Rate for Payer: Quartz Commercial |
$3,741.60
|
| Rate for Payer: WEA Trust Commercial |
$3,429.80
|
| Rate for Payer: WPS Commercial |
$4,619.01
|
|
|
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 |
$3,300.64 |
| Max. Negotiated Rate |
$6,197.12 |
| Rate for Payer: Aetna Commercial |
$6,062.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,792.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,570.08
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,197.12
|
| Rate for Payer: Health EOS Commercial |
$5,995.04
|
| Rate for Payer: HFN Commercial |
$6,197.12
|
| Rate for Payer: Multiplan Commercial |
$5,388.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,041.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,197.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,300.64
|
| Rate for Payer: Quartz Commercial |
$4,041.60
|
| Rate for Payer: WEA Trust Commercial |
$3,704.80
|
| Rate for Payer: WPS Commercial |
$4,989.36
|
|
|
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 |
$1,886.08 |
| Max. Negotiated Rate |
$26,944.00 |
| Rate for Payer: Aetna Commercial |
$6,062.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,792.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,886.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,378.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,368.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,233.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,570.08
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,197.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,769.47
|
| Rate for Payer: Health EOS Commercial |
$5,995.04
|
| Rate for Payer: HFN Commercial |
$6,197.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,052.00
|
| Rate for Payer: Multiplan Commercial |
$5,388.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,041.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,197.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,300.64
|
| Rate for Payer: Quartz Commercial |
$4,378.40
|
| Rate for Payer: Quartz Medicare Advantage |
$4,041.60
|
| Rate for Payer: The Alliance Commercial |
$26,944.00
|
| Rate for Payer: WEA Trust Commercial |
$3,704.80
|
| Rate for Payer: WPS Commercial |
$4,989.36
|
|
|
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 |
$3,300.64 |
| Max. Negotiated Rate |
$6,197.12 |
| Rate for Payer: Aetna Commercial |
$6,062.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,792.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,570.08
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,197.12
|
| Rate for Payer: Health EOS Commercial |
$5,995.04
|
| Rate for Payer: HFN Commercial |
$6,197.12
|
| Rate for Payer: Multiplan Commercial |
$5,388.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,041.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,197.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,300.64
|
| Rate for Payer: Quartz Commercial |
$4,041.60
|
| Rate for Payer: WEA Trust Commercial |
$3,704.80
|
| Rate for Payer: WPS Commercial |
$4,989.36
|
|
|
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 |
$1,886.08 |
| Max. Negotiated Rate |
$26,944.00 |
| Rate for Payer: Aetna Commercial |
$6,062.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,792.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,886.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,378.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,368.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,233.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,570.08
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,197.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,769.47
|
| Rate for Payer: Health EOS Commercial |
$5,995.04
|
| Rate for Payer: HFN Commercial |
$6,197.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,052.00
|
| Rate for Payer: Multiplan Commercial |
$5,388.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,041.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,197.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,300.64
|
| Rate for Payer: Quartz Commercial |
$4,378.40
|
| Rate for Payer: Quartz Medicare Advantage |
$4,041.60
|
| Rate for Payer: The Alliance Commercial |
$26,944.00
|
| Rate for Payer: WEA Trust Commercial |
$3,704.80
|
| Rate for Payer: WPS Commercial |
$4,989.36
|
|
|
PLATE 2.4 6HL/4H LT 04.111.641
|
Facility
|
IP
|
$6,987.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,423.63 |
| Max. Negotiated Rate |
$6,428.04 |
| Rate for Payer: Aetna Commercial |
$6,288.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,008.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,703.11
|
| Rate for Payer: Cash Price |
$2,096.10
|
| Rate for Payer: Cigna Commercial |
$6,428.04
|
| Rate for Payer: Health EOS Commercial |
$6,218.43
|
| Rate for Payer: HFN Commercial |
$6,428.04
|
| Rate for Payer: Multiplan Commercial |
$5,589.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,192.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,428.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,423.63
|
| Rate for Payer: Quartz Commercial |
$4,192.20
|
| Rate for Payer: WEA Trust Commercial |
$3,842.85
|
| Rate for Payer: WPS Commercial |
$5,175.27
|
|
|
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 |
$1,956.36 |
| Max. Negotiated Rate |
$27,948.00 |
| Rate for Payer: Aetna Commercial |
$6,288.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,008.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,956.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,541.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,493.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,353.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,703.11
|
| Rate for Payer: Cash Price |
$2,096.10
|
| Rate for Payer: Cigna Commercial |
$6,428.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,909.93
|
| Rate for Payer: Health EOS Commercial |
$6,218.43
|
| Rate for Payer: HFN Commercial |
$6,428.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,240.25
|
| Rate for Payer: Multiplan Commercial |
$5,589.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,192.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,428.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,423.63
|
| Rate for Payer: Quartz Commercial |
$4,541.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,192.20
|
| Rate for Payer: The Alliance Commercial |
$27,948.00
|
| Rate for Payer: WEA Trust Commercial |
$3,842.85
|
| Rate for Payer: WPS Commercial |
$5,175.27
|
|
|
PLATE 2.4 6HL/4H RT 04.111.640
|
Facility
|
IP
|
$6,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,297.21 |
| Max. Negotiated Rate |
$6,190.68 |
| Rate for Payer: Aetna Commercial |
$6,056.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,786.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,566.37
|
| Rate for Payer: Cash Price |
$2,018.70
|
| Rate for Payer: Cigna Commercial |
$6,190.68
|
| Rate for Payer: Health EOS Commercial |
$5,988.81
|
| Rate for Payer: HFN Commercial |
$6,190.68
|
| Rate for Payer: Multiplan Commercial |
$5,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,037.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,190.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,297.21
|
| Rate for Payer: Quartz Commercial |
$4,037.40
|
| Rate for Payer: WEA Trust Commercial |
$3,700.95
|
| Rate for Payer: WPS Commercial |
$4,984.17
|
|
|
PLATE 2.4 6HL/4H RT 04.111.640
|
Facility
|
OP
|
$6,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,884.12 |
| Max. Negotiated Rate |
$26,916.00 |
| Rate for Payer: Aetna Commercial |
$6,056.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,786.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,884.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,373.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,364.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,229.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,566.37
|
| Rate for Payer: Cash Price |
$2,018.70
|
| Rate for Payer: Cigna Commercial |
$6,190.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,765.55
|
| Rate for Payer: Health EOS Commercial |
$5,988.81
|
| Rate for Payer: HFN Commercial |
$6,190.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,046.75
|
| Rate for Payer: Multiplan Commercial |
$5,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,037.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,190.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,297.21
|
| Rate for Payer: Quartz Commercial |
$4,373.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,037.40
|
| Rate for Payer: The Alliance Commercial |
$26,916.00
|
| Rate for Payer: WEA Trust Commercial |
$3,700.95
|
| Rate for Payer: WPS Commercial |
$4,984.17
|
|
|
PLATE 2.4 6HL/5H LT 04.111.651
|
Facility
|
OP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,953.84 |
| Max. Negotiated Rate |
$27,912.00 |
| Rate for Payer: Aetna Commercial |
$6,280.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,001.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,953.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,535.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,349.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,698.34
|
| Rate for Payer: Cash Price |
$2,093.40
|
| Rate for Payer: Cigna Commercial |
$6,419.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,904.89
|
| Rate for Payer: Health EOS Commercial |
$6,210.42
|
| Rate for Payer: HFN Commercial |
$6,419.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,233.50
|
| Rate for Payer: Multiplan Commercial |
$5,582.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,186.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,419.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,419.22
|
| Rate for Payer: Quartz Commercial |
$4,535.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,186.80
|
| Rate for Payer: The Alliance Commercial |
$27,912.00
|
| Rate for Payer: WEA Trust Commercial |
$3,837.90
|
| Rate for Payer: WPS Commercial |
$5,168.60
|
|
|
PLATE 2.4 6HL/5H LT 04.111.651
|
Facility
|
IP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,419.22 |
| Max. Negotiated Rate |
$6,419.76 |
| Rate for Payer: Aetna Commercial |
$6,280.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,001.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,698.34
|
| Rate for Payer: Cash Price |
$2,093.40
|
| Rate for Payer: Cigna Commercial |
$6,419.76
|
| Rate for Payer: Health EOS Commercial |
$6,210.42
|
| Rate for Payer: HFN Commercial |
$6,419.76
|
| Rate for Payer: Multiplan Commercial |
$5,582.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,186.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,419.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,419.22
|
| Rate for Payer: Quartz Commercial |
$4,186.80
|
| Rate for Payer: WEA Trust Commercial |
$3,837.90
|
| Rate for Payer: WPS Commercial |
$5,168.60
|
|
|
PLATE 2.4 6HL/5H RT 04.111.650
|
Facility
|
IP
|
$7,247.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,551.03 |
| Max. Negotiated Rate |
$6,667.24 |
| Rate for Payer: Aetna Commercial |
$6,522.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,232.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,840.91
|
| Rate for Payer: Cash Price |
$2,174.10
|
| Rate for Payer: Cigna Commercial |
$6,667.24
|
| Rate for Payer: Health EOS Commercial |
$6,449.83
|
| Rate for Payer: HFN Commercial |
$6,667.24
|
| Rate for Payer: Multiplan Commercial |
$5,797.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,348.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,667.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,551.03
|
| Rate for Payer: Quartz Commercial |
$4,348.20
|
| Rate for Payer: WEA Trust Commercial |
$3,985.85
|
| Rate for Payer: WPS Commercial |
$5,367.85
|
|
|
PLATE 2.4 6HL/5H RT 04.111.650
|
Facility
|
OP
|
$7,247.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,029.16 |
| Max. Negotiated Rate |
$28,988.00 |
| Rate for Payer: Aetna Commercial |
$6,522.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,232.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,029.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,710.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,623.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,478.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,840.91
|
| Rate for Payer: Cash Price |
$2,174.10
|
| Rate for Payer: Cigna Commercial |
$6,667.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,055.42
|
| Rate for Payer: Health EOS Commercial |
$6,449.83
|
| Rate for Payer: HFN Commercial |
$6,667.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,435.25
|
| Rate for Payer: Multiplan Commercial |
$5,797.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,348.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,667.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,551.03
|
| Rate for Payer: Quartz Commercial |
$4,710.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,348.20
|
| Rate for Payer: The Alliance Commercial |
$28,988.00
|
| Rate for Payer: WEA Trust Commercial |
$3,985.85
|
| Rate for Payer: WPS Commercial |
$5,367.85
|
|
|
PLATE 2.4 6HL LT DISTAL RADIUS
|
Facility
|
IP
|
$6,501.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,185.49 |
| Max. Negotiated Rate |
$5,980.92 |
| Rate for Payer: Aetna Commercial |
$5,850.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,590.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,445.53
|
| Rate for Payer: Cash Price |
$1,950.30
|
| Rate for Payer: Cigna Commercial |
$5,980.92
|
| Rate for Payer: Health EOS Commercial |
$5,785.89
|
| Rate for Payer: HFN Commercial |
$5,980.92
|
| Rate for Payer: Multiplan Commercial |
$5,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,900.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,980.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,185.49
|
| Rate for Payer: Quartz Commercial |
$3,900.60
|
| Rate for Payer: WEA Trust Commercial |
$3,575.55
|
| Rate for Payer: WPS Commercial |
$4,815.29
|
|
|
PLATE 2.4 6HL LT DISTAL RADIUS
|
Facility
|
OP
|
$6,501.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,820.28 |
| Max. Negotiated Rate |
$26,004.00 |
| Rate for Payer: Aetna Commercial |
$5,850.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,590.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,820.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,225.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,250.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,120.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,445.53
|
| Rate for Payer: Cash Price |
$1,950.30
|
| Rate for Payer: Cigna Commercial |
$5,980.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,637.96
|
| Rate for Payer: Health EOS Commercial |
$5,785.89
|
| Rate for Payer: HFN Commercial |
$5,980.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,875.75
|
| Rate for Payer: Multiplan Commercial |
$5,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,900.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,980.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,185.49
|
| Rate for Payer: Quartz Commercial |
$4,225.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,900.60
|
| Rate for Payer: The Alliance Commercial |
$26,004.00
|
| Rate for Payer: WEA Trust Commercial |
$3,575.55
|
| Rate for Payer: WPS Commercial |
$4,815.29
|
|
|
PLATE 2.4 7HL/2H LT 04.111.721
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,055.64 |
| Max. Negotiated Rate |
$5,737.12 |
| Rate for Payer: Aetna Commercial |
$5,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,305.08
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,737.12
|
| Rate for Payer: Health EOS Commercial |
$5,550.04
|
| Rate for Payer: HFN Commercial |
$5,737.12
|
| Rate for Payer: Multiplan Commercial |
$4,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.64
|
| Rate for Payer: Quartz Commercial |
$3,741.60
|
| Rate for Payer: WEA Trust Commercial |
$3,429.80
|
| Rate for Payer: WPS Commercial |
$4,619.01
|
|
|
PLATE 2.4 7HL/2H LT 04.111.721
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,746.08 |
| Max. Negotiated Rate |
$24,944.00 |
| Rate for Payer: Aetna Commercial |
$5,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,746.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,053.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,993.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,305.08
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,737.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,489.67
|
| Rate for Payer: Health EOS Commercial |
$5,550.04
|
| Rate for Payer: HFN Commercial |
$5,737.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,677.00
|
| Rate for Payer: Multiplan Commercial |
$4,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.64
|
| Rate for Payer: Quartz Commercial |
$4,053.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,741.60
|
| Rate for Payer: The Alliance Commercial |
$24,944.00
|
| Rate for Payer: WEA Trust Commercial |
$3,429.80
|
| Rate for Payer: WPS Commercial |
$4,619.01
|
|
|
PLATE 2.4 7HL/2H RT 04.111.720
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,055.64 |
| Max. Negotiated Rate |
$5,737.12 |
| Rate for Payer: Aetna Commercial |
$5,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,305.08
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,737.12
|
| Rate for Payer: Health EOS Commercial |
$5,550.04
|
| Rate for Payer: HFN Commercial |
$5,737.12
|
| Rate for Payer: Multiplan Commercial |
$4,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.64
|
| Rate for Payer: Quartz Commercial |
$3,741.60
|
| Rate for Payer: WEA Trust Commercial |
$3,429.80
|
| Rate for Payer: WPS Commercial |
$4,619.01
|
|
|
PLATE 2.4 7HL/2H RT 04.111.720
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,746.08 |
| Max. Negotiated Rate |
$24,944.00 |
| Rate for Payer: Aetna Commercial |
$5,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,362.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,746.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,053.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,993.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,305.08
|
| Rate for Payer: Cash Price |
$1,870.80
|
| Rate for Payer: Cigna Commercial |
$5,737.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,489.67
|
| Rate for Payer: Health EOS Commercial |
$5,550.04
|
| Rate for Payer: HFN Commercial |
$5,737.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,677.00
|
| Rate for Payer: Multiplan Commercial |
$4,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,055.64
|
| Rate for Payer: Quartz Commercial |
$4,053.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,741.60
|
| Rate for Payer: The Alliance Commercial |
$24,944.00
|
| Rate for Payer: WEA Trust Commercial |
$3,429.80
|
| Rate for Payer: WPS Commercial |
$4,619.01
|
|
|
PLATE 2.4 7HL/3H LT 04.111.731
|
Facility
|
OP
|
$6,486.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,816.08 |
| Max. Negotiated Rate |
$25,944.00 |
| Rate for Payer: Aetna Commercial |
$5,837.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,816.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,215.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,243.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,113.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.58
|
| Rate for Payer: Cash Price |
$1,945.80
|
| Rate for Payer: Cigna Commercial |
$5,967.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,629.57
|
| Rate for Payer: Health EOS Commercial |
$5,772.54
|
| Rate for Payer: HFN Commercial |
$5,967.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,864.50
|
| Rate for Payer: Multiplan Commercial |
$5,188.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,891.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,967.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,178.14
|
| Rate for Payer: Quartz Commercial |
$4,215.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,891.60
|
| Rate for Payer: The Alliance Commercial |
$25,944.00
|
| Rate for Payer: WEA Trust Commercial |
$3,567.30
|
| Rate for Payer: WPS Commercial |
$4,804.18
|
|
|
PLATE 2.4 7HL/3H LT 04.111.731
|
Facility
|
IP
|
$6,486.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,178.14 |
| Max. Negotiated Rate |
$5,967.12 |
| Rate for Payer: Aetna Commercial |
$5,837.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,577.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,437.58
|
| Rate for Payer: Cash Price |
$1,945.80
|
| Rate for Payer: Cigna Commercial |
$5,967.12
|
| Rate for Payer: Health EOS Commercial |
$5,772.54
|
| Rate for Payer: HFN Commercial |
$5,967.12
|
| Rate for Payer: Multiplan Commercial |
$5,188.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,891.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,967.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,178.14
|
| Rate for Payer: Quartz Commercial |
$3,891.60
|
| Rate for Payer: WEA Trust Commercial |
$3,567.30
|
| Rate for Payer: WPS Commercial |
$4,804.18
|
|
|
PLATE 2.4 7HL/3H RT 04.111.730
|
Facility
|
OP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,886.08 |
| Max. Negotiated Rate |
$26,944.00 |
| Rate for Payer: Aetna Commercial |
$6,062.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,792.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,886.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,378.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,368.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,233.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,570.08
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,197.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,769.47
|
| Rate for Payer: Health EOS Commercial |
$5,995.04
|
| Rate for Payer: HFN Commercial |
$6,197.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,052.00
|
| Rate for Payer: Multiplan Commercial |
$5,388.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,041.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,197.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,300.64
|
| Rate for Payer: Quartz Commercial |
$4,378.40
|
| Rate for Payer: Quartz Medicare Advantage |
$4,041.60
|
| Rate for Payer: The Alliance Commercial |
$26,944.00
|
| Rate for Payer: WEA Trust Commercial |
$3,704.80
|
| Rate for Payer: WPS Commercial |
$4,989.36
|
|
|
PLATE 2.4 7HL/3H RT 04.111.730
|
Facility
|
IP
|
$6,736.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,300.64 |
| Max. Negotiated Rate |
$6,197.12 |
| Rate for Payer: Aetna Commercial |
$6,062.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,792.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,570.08
|
| Rate for Payer: Cash Price |
$2,020.80
|
| Rate for Payer: Cigna Commercial |
$6,197.12
|
| Rate for Payer: Health EOS Commercial |
$5,995.04
|
| Rate for Payer: HFN Commercial |
$6,197.12
|
| Rate for Payer: Multiplan Commercial |
$5,388.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,041.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,197.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,300.64
|
| Rate for Payer: Quartz Commercial |
$4,041.60
|
| Rate for Payer: WEA Trust Commercial |
$3,704.80
|
| Rate for Payer: WPS Commercial |
$4,989.36
|
|
