|
PLATE 2.4 7HL/4H LT 04.111.741
|
Facility
|
OP
|
$6,987.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966691
|
|
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 7HL/4H LT 04.111.741
|
Facility
|
IP
|
$6,987.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966691
|
|
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 7HL/4H RT 04.111.740
|
Facility
|
IP
|
$6,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966692
|
|
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 7HL/4H RT 04.111.740
|
Facility
|
OP
|
$6,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966692
|
|
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 7HL/5H LT 04.111.751
|
Facility
|
OP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966693
|
|
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 7HL/5H LT 04.111.751
|
Facility
|
IP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966693
|
|
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 7HL/5H RT 04.111.750
|
Facility
|
IP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966694
|
|
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 7HL/5H RT 04.111.750
|
Facility
|
OP
|
$6,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966694
|
|
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 DISTAL RADIUS 6HL HEAD 3HL SHAFT LT 02.111.631S
|
Facility
|
OP
|
$7,354.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3603522
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,059.12 |
| Max. Negotiated Rate |
$29,416.00 |
| Rate for Payer: Aetna Commercial |
$6,618.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,324.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,059.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,780.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,677.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,529.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,897.62
|
| Rate for Payer: Cash Price |
$2,206.20
|
| Rate for Payer: Cigna Commercial |
$6,765.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,115.30
|
| Rate for Payer: Health EOS Commercial |
$6,545.06
|
| Rate for Payer: HFN Commercial |
$6,765.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,515.50
|
| Rate for Payer: Multiplan Commercial |
$5,883.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,412.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,765.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,603.46
|
| Rate for Payer: Quartz Commercial |
$4,780.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,412.40
|
| Rate for Payer: The Alliance Commercial |
$29,416.00
|
| Rate for Payer: WEA Trust Commercial |
$4,044.70
|
| Rate for Payer: WPS Commercial |
$5,447.11
|
|
|
PLATE 2.4 DISTAL RADIUS 6HL HEAD 3HL SHAFT LT 02.111.631S
|
Facility
|
IP
|
$7,354.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3603522
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,603.46 |
| Max. Negotiated Rate |
$6,765.68 |
| Rate for Payer: Aetna Commercial |
$6,618.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,324.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,897.62
|
| Rate for Payer: Cash Price |
$2,206.20
|
| Rate for Payer: Cigna Commercial |
$6,765.68
|
| Rate for Payer: Health EOS Commercial |
$6,545.06
|
| Rate for Payer: HFN Commercial |
$6,765.68
|
| Rate for Payer: Multiplan Commercial |
$5,883.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,412.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,765.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,603.46
|
| Rate for Payer: Quartz Commercial |
$4,412.40
|
| Rate for Payer: WEA Trust Commercial |
$4,044.70
|
| Rate for Payer: WPS Commercial |
$5,447.11
|
|
|
PLATE 2.4 DISTAL RADIUS 6 HOLE 2 COLUMN RIGHT 02.111.650S
|
Facility
|
OP
|
$5,258.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3529515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.24 |
| Max. Negotiated Rate |
$21,032.00 |
| Rate for Payer: Aetna Commercial |
$4,732.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,521.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,472.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,417.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,629.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,523.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,786.74
|
| Rate for Payer: Cash Price |
$1,577.40
|
| Rate for Payer: Cigna Commercial |
$4,837.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,942.38
|
| Rate for Payer: Health EOS Commercial |
$4,679.62
|
| Rate for Payer: HFN Commercial |
$4,837.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,943.50
|
| Rate for Payer: Multiplan Commercial |
$4,206.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,837.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,576.42
|
| Rate for Payer: Quartz Commercial |
$3,417.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,154.80
|
| Rate for Payer: The Alliance Commercial |
$21,032.00
|
| Rate for Payer: WEA Trust Commercial |
$2,891.90
|
| Rate for Payer: WPS Commercial |
$3,894.60
|
|
|
PLATE 2.4 DISTAL RADIUS 6 HOLE 2 COLUMN RIGHT 02.111.650S
|
Facility
|
IP
|
$5,258.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3529515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,576.42 |
| Max. Negotiated Rate |
$4,837.36 |
| Rate for Payer: Aetna Commercial |
$4,732.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,521.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,786.74
|
| Rate for Payer: Cash Price |
$1,577.40
|
| Rate for Payer: Cigna Commercial |
$4,837.36
|
| Rate for Payer: Health EOS Commercial |
$4,679.62
|
| Rate for Payer: HFN Commercial |
$4,837.36
|
| Rate for Payer: Multiplan Commercial |
$4,206.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,837.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,576.42
|
| Rate for Payer: Quartz Commercial |
$3,154.80
|
| Rate for Payer: WEA Trust Commercial |
$2,891.90
|
| Rate for Payer: WPS Commercial |
$3,894.60
|
|
|
PLATE 2.4 DIST RAD 6HL/4HL LT
|
Facility
|
IP
|
$7,036.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,447.64 |
| Max. Negotiated Rate |
$6,473.12 |
| Rate for Payer: Aetna Commercial |
$6,332.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,050.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,729.08
|
| Rate for Payer: Cash Price |
$2,110.80
|
| Rate for Payer: Cigna Commercial |
$6,473.12
|
| Rate for Payer: Health EOS Commercial |
$6,262.04
|
| Rate for Payer: HFN Commercial |
$6,473.12
|
| Rate for Payer: Multiplan Commercial |
$5,628.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,221.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,473.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,447.64
|
| Rate for Payer: Quartz Commercial |
$4,221.60
|
| Rate for Payer: WEA Trust Commercial |
$3,869.80
|
| Rate for Payer: WPS Commercial |
$5,211.57
|
|
|
PLATE 2.4 DIST RAD 6HL/4HL LT
|
Facility
|
OP
|
$7,036.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,970.08 |
| Max. Negotiated Rate |
$28,144.00 |
| Rate for Payer: Aetna Commercial |
$6,332.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,050.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,970.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,573.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,518.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,377.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,729.08
|
| Rate for Payer: Cash Price |
$2,110.80
|
| Rate for Payer: Cigna Commercial |
$6,473.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,937.35
|
| Rate for Payer: Health EOS Commercial |
$6,262.04
|
| Rate for Payer: HFN Commercial |
$6,473.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,277.00
|
| Rate for Payer: Multiplan Commercial |
$5,628.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,221.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,473.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,447.64
|
| Rate for Payer: Quartz Commercial |
$4,573.40
|
| Rate for Payer: Quartz Medicare Advantage |
$4,221.60
|
| Rate for Payer: The Alliance Commercial |
$28,144.00
|
| Rate for Payer: WEA Trust Commercial |
$3,869.80
|
| Rate for Payer: WPS Commercial |
$5,211.57
|
|
|
PLATE 2.4 DIST RAD L- 2HL/4HL
|
Facility
|
IP
|
$6,015.00
|
|
| Hospital Charge Code |
2966326
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,947.35 |
| Max. Negotiated Rate |
$5,533.80 |
| Rate for Payer: Aetna Commercial |
$5,413.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,172.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,187.95
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cigna Commercial |
$5,533.80
|
| Rate for Payer: Health EOS Commercial |
$5,353.35
|
| Rate for Payer: HFN Commercial |
$5,533.80
|
| Rate for Payer: Multiplan Commercial |
$4,812.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,609.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,533.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,947.35
|
| Rate for Payer: Quartz Commercial |
$3,609.00
|
| Rate for Payer: WEA Trust Commercial |
$3,308.25
|
| Rate for Payer: WPS Commercial |
$4,455.31
|
|
|
PLATE 2.4 DIST RAD L- 2HL/4HL
|
Facility
|
OP
|
$6,015.00
|
|
| Hospital Charge Code |
2966326
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,684.20 |
| Max. Negotiated Rate |
$24,060.00 |
| Rate for Payer: Aetna Commercial |
$5,413.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,172.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,684.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,909.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,007.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,887.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,187.95
|
| Rate for Payer: Cash Price |
$1,804.50
|
| Rate for Payer: Cigna Commercial |
$5,533.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,365.99
|
| Rate for Payer: Health EOS Commercial |
$5,353.35
|
| Rate for Payer: HFN Commercial |
$5,533.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,511.25
|
| Rate for Payer: Multiplan Commercial |
$4,812.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,609.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,533.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,947.35
|
| Rate for Payer: Quartz Commercial |
$3,909.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3,609.00
|
| Rate for Payer: The Alliance Commercial |
$24,060.00
|
| Rate for Payer: WEA Trust Commercial |
$3,308.25
|
| Rate for Payer: WPS Commercial |
$4,455.31
|
|
|
PLATE 2.4 DIST RAD VOLAR LT SHORT 442.491
|
Facility
|
OP
|
$5,346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,496.88 |
| Max. Negotiated Rate |
$21,384.00 |
| Rate for Payer: Aetna Commercial |
$4,811.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,597.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,496.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,474.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,673.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,566.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,833.38
|
| Rate for Payer: Cash Price |
$1,603.80
|
| Rate for Payer: Cigna Commercial |
$4,918.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,991.62
|
| Rate for Payer: Health EOS Commercial |
$4,757.94
|
| Rate for Payer: HFN Commercial |
$4,918.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,009.50
|
| Rate for Payer: Multiplan Commercial |
$4,276.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,207.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,918.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,619.54
|
| Rate for Payer: Quartz Commercial |
$3,474.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,207.60
|
| Rate for Payer: The Alliance Commercial |
$21,384.00
|
| Rate for Payer: WEA Trust Commercial |
$2,940.30
|
| Rate for Payer: WPS Commercial |
$3,959.78
|
|
|
PLATE 2.4 DIST RAD VOLAR LT SHORT 442.491
|
Facility
|
IP
|
$5,346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,619.54 |
| Max. Negotiated Rate |
$4,918.32 |
| Rate for Payer: Aetna Commercial |
$4,811.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,597.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,833.38
|
| Rate for Payer: Cash Price |
$1,603.80
|
| Rate for Payer: Cigna Commercial |
$4,918.32
|
| Rate for Payer: Health EOS Commercial |
$4,757.94
|
| Rate for Payer: HFN Commercial |
$4,918.32
|
| Rate for Payer: Multiplan Commercial |
$4,276.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,207.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,918.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,619.54
|
| Rate for Payer: Quartz Commercial |
$3,207.60
|
| Rate for Payer: WEA Trust Commercial |
$2,940.30
|
| Rate for Payer: WPS Commercial |
$3,959.78
|
|
|
PLATE 2.4 DIST RAD VOLAR RT LONG 442.494
|
Facility
|
IP
|
$5,663.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632614
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,774.87 |
| Max. Negotiated Rate |
$5,209.96 |
| Rate for Payer: Aetna Commercial |
$5,096.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.39
|
| Rate for Payer: Cash Price |
$1,698.90
|
| Rate for Payer: Cigna Commercial |
$5,209.96
|
| Rate for Payer: Health EOS Commercial |
$5,040.07
|
| Rate for Payer: HFN Commercial |
$5,209.96
|
| Rate for Payer: Multiplan Commercial |
$4,530.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,397.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.87
|
| Rate for Payer: Quartz Commercial |
$3,397.80
|
| Rate for Payer: WEA Trust Commercial |
$3,114.65
|
| Rate for Payer: WPS Commercial |
$4,194.58
|
|
|
PLATE 2.4 DIST RAD VOLAR RT LONG 442.494
|
Facility
|
OP
|
$5,663.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632614
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,585.64 |
| Max. Negotiated Rate |
$22,652.00 |
| Rate for Payer: Aetna Commercial |
$5,096.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,585.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,680.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,831.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,718.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.39
|
| Rate for Payer: Cash Price |
$1,698.90
|
| Rate for Payer: Cigna Commercial |
$5,209.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,169.01
|
| Rate for Payer: Health EOS Commercial |
$5,040.07
|
| Rate for Payer: HFN Commercial |
$5,209.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,247.25
|
| Rate for Payer: Multiplan Commercial |
$4,530.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,397.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.87
|
| Rate for Payer: Quartz Commercial |
$3,680.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,397.80
|
| Rate for Payer: The Alliance Commercial |
$22,652.00
|
| Rate for Payer: WEA Trust Commercial |
$3,114.65
|
| Rate for Payer: WPS Commercial |
$4,194.58
|
|
|
PLATE 2.4 DIST RAD VOLAR RT SHORT 442.493
|
Facility
|
OP
|
$5,346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,496.88 |
| Max. Negotiated Rate |
$21,384.00 |
| Rate for Payer: Aetna Commercial |
$4,811.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,597.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,496.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,474.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,673.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,566.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,833.38
|
| Rate for Payer: Cash Price |
$1,603.80
|
| Rate for Payer: Cigna Commercial |
$4,918.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,991.62
|
| Rate for Payer: Health EOS Commercial |
$4,757.94
|
| Rate for Payer: HFN Commercial |
$4,918.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,009.50
|
| Rate for Payer: Multiplan Commercial |
$4,276.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,207.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,918.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,619.54
|
| Rate for Payer: Quartz Commercial |
$3,474.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,207.60
|
| Rate for Payer: The Alliance Commercial |
$21,384.00
|
| Rate for Payer: WEA Trust Commercial |
$2,940.30
|
| Rate for Payer: WPS Commercial |
$3,959.78
|
|
|
PLATE 2.4 DIST RAD VOLAR RT SHORT 442.493
|
Facility
|
IP
|
$5,346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,619.54 |
| Max. Negotiated Rate |
$4,918.32 |
| Rate for Payer: Aetna Commercial |
$4,811.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,597.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,833.38
|
| Rate for Payer: Cash Price |
$1,603.80
|
| Rate for Payer: Cigna Commercial |
$4,918.32
|
| Rate for Payer: Health EOS Commercial |
$4,757.94
|
| Rate for Payer: HFN Commercial |
$4,918.32
|
| Rate for Payer: Multiplan Commercial |
$4,276.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,207.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,918.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,619.54
|
| Rate for Payer: Quartz Commercial |
$3,207.60
|
| Rate for Payer: WEA Trust Commercial |
$2,940.30
|
| Rate for Payer: WPS Commercial |
$3,959.78
|
|
|
PLATE 2.4 ST-LG DST/RD 442.490
|
Facility
|
IP
|
$4,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.92 |
| Max. Negotiated Rate |
$4,055.36 |
| Rate for Payer: Aetna Commercial |
$3,967.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,790.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,336.24
|
| Rate for Payer: Cash Price |
$1,322.40
|
| Rate for Payer: Cigna Commercial |
$4,055.36
|
| Rate for Payer: Health EOS Commercial |
$3,923.12
|
| Rate for Payer: HFN Commercial |
$4,055.36
|
| Rate for Payer: Multiplan Commercial |
$3,526.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,644.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,055.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,159.92
|
| Rate for Payer: Quartz Commercial |
$2,644.80
|
| Rate for Payer: WEA Trust Commercial |
$2,424.40
|
| Rate for Payer: WPS Commercial |
$3,265.01
|
|
|
PLATE 2.4 ST-LG DST/RD 442.490
|
Facility
|
OP
|
$4,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,234.24 |
| Max. Negotiated Rate |
$17,632.00 |
| Rate for Payer: Aetna Commercial |
$3,967.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,790.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,234.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,865.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,204.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,115.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,336.24
|
| Rate for Payer: Cash Price |
$1,322.40
|
| Rate for Payer: Cigna Commercial |
$4,055.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,466.72
|
| Rate for Payer: Health EOS Commercial |
$3,923.12
|
| Rate for Payer: HFN Commercial |
$4,055.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,306.00
|
| Rate for Payer: Multiplan Commercial |
$3,526.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,644.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,055.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,159.92
|
| Rate for Payer: Quartz Commercial |
$2,865.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,644.80
|
| Rate for Payer: The Alliance Commercial |
$17,632.00
|
| Rate for Payer: WEA Trust Commercial |
$2,424.40
|
| Rate for Payer: WPS Commercial |
$3,265.01
|
|
|
PLATE 2.4 ST-SH DST.RD 442.479
|
Facility
|
IP
|
$4,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,050.16 |
| Max. Negotiated Rate |
$3,849.28 |
| Rate for Payer: Aetna Commercial |
$3,765.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,598.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,217.52
|
| Rate for Payer: Cash Price |
$1,255.20
|
| Rate for Payer: Cigna Commercial |
$3,849.28
|
| Rate for Payer: Health EOS Commercial |
$3,723.76
|
| Rate for Payer: HFN Commercial |
$3,849.28
|
| Rate for Payer: Multiplan Commercial |
$3,347.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,510.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,849.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,050.16
|
| Rate for Payer: Quartz Commercial |
$2,510.40
|
| Rate for Payer: WEA Trust Commercial |
$2,301.20
|
| Rate for Payer: WPS Commercial |
$3,099.09
|
|
