|
PLATE 2HH/3HS L -90 442.500
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.54 |
| Max. Negotiated Rate |
$4,090.32 |
| Rate for Payer: Aetna Commercial |
$4,001.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,823.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,356.38
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$4,090.32
|
| Rate for Payer: Health EOS Commercial |
$3,956.94
|
| Rate for Payer: HFN Commercial |
$4,090.32
|
| Rate for Payer: Multiplan Commercial |
$3,556.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,090.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,178.54
|
| Rate for Payer: Quartz Commercial |
$2,667.60
|
| Rate for Payer: WEA Trust Commercial |
$2,445.30
|
| Rate for Payer: WPS Commercial |
$3,293.03
|
|
|
PLATE 2HH/3HS L -90 442.500
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,244.88 |
| Max. Negotiated Rate |
$4,090.32 |
| Rate for Payer: Aetna Commercial |
$4,001.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,823.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,244.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,889.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,134.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,356.38
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$4,090.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,488.05
|
| Rate for Payer: Health EOS Commercial |
$3,956.94
|
| Rate for Payer: HFN Commercial |
$4,090.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,334.50
|
| Rate for Payer: Multiplan Commercial |
$3,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,667.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,090.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,178.54
|
| Rate for Payer: Quartz Commercial |
$2,889.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,667.60
|
| Rate for Payer: The Alliance Commercial |
$2,223.00
|
| Rate for Payer: WEA Trust Commercial |
$2,445.30
|
| Rate for Payer: WPS Commercial |
$3,293.03
|
|
|
PLATE 2HH/3HS L +90 442.502
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,244.88 |
| Max. Negotiated Rate |
$4,090.32 |
| Rate for Payer: Aetna Commercial |
$4,001.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,823.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,244.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,889.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,134.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,356.38
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$4,090.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,488.05
|
| Rate for Payer: Health EOS Commercial |
$3,956.94
|
| Rate for Payer: HFN Commercial |
$4,090.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,334.50
|
| Rate for Payer: Multiplan Commercial |
$3,556.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,667.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,090.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,178.54
|
| Rate for Payer: Quartz Commercial |
$2,889.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,667.60
|
| Rate for Payer: The Alliance Commercial |
$2,223.00
|
| Rate for Payer: WEA Trust Commercial |
$2,445.30
|
| Rate for Payer: WPS Commercial |
$3,293.03
|
|
|
PLATE 2HH/3HS L +90 442.502
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.54 |
| Max. Negotiated Rate |
$4,090.32 |
| Rate for Payer: Aetna Commercial |
$4,001.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,823.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,356.38
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$4,090.32
|
| Rate for Payer: Health EOS Commercial |
$3,956.94
|
| Rate for Payer: HFN Commercial |
$4,090.32
|
| Rate for Payer: Multiplan Commercial |
$3,556.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,090.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,178.54
|
| Rate for Payer: Quartz Commercial |
$2,667.60
|
| Rate for Payer: WEA Trust Commercial |
$2,445.30
|
| Rate for Payer: WPS Commercial |
$3,293.03
|
|
|
PLATE 2HH/4HS L -90 442.501
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,292.18 |
| Max. Negotiated Rate |
$4,303.69 |
| Rate for Payer: Aetna Commercial |
$4,210.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.30
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,303.69
|
| Rate for Payer: Health EOS Commercial |
$4,163.35
|
| Rate for Payer: HFN Commercial |
$4,303.69
|
| Rate for Payer: Multiplan Commercial |
$3,742.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.18
|
| Rate for Payer: Quartz Commercial |
$2,806.75
|
| Rate for Payer: WEA Trust Commercial |
$2,572.86
|
| Rate for Payer: WPS Commercial |
$3,464.81
|
|
|
PLATE 2HH/4HS L -90 442.501
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,309.82 |
| Max. Negotiated Rate |
$4,303.69 |
| Rate for Payer: Aetna Commercial |
$4,210.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,309.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,040.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,338.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,245.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.30
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,303.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,617.84
|
| Rate for Payer: Health EOS Commercial |
$4,163.35
|
| Rate for Payer: HFN Commercial |
$4,303.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,508.44
|
| Rate for Payer: Multiplan Commercial |
$3,742.34
|
| Rate for Payer: NAPHCARE Commercial |
$2,806.75
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.18
|
| Rate for Payer: Quartz Commercial |
$3,040.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,806.75
|
| Rate for Payer: The Alliance Commercial |
$2,338.96
|
| Rate for Payer: WEA Trust Commercial |
$2,572.86
|
| Rate for Payer: WPS Commercial |
$3,464.81
|
|
|
PLATE 2HH/4HS L +90 442.503
|
Facility
|
OP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,309.82 |
| Max. Negotiated Rate |
$4,303.69 |
| Rate for Payer: Aetna Commercial |
$4,210.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,309.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,040.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,338.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,245.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.30
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,303.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,617.84
|
| Rate for Payer: Health EOS Commercial |
$4,163.35
|
| Rate for Payer: HFN Commercial |
$4,303.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,508.44
|
| Rate for Payer: Multiplan Commercial |
$3,742.34
|
| Rate for Payer: NAPHCARE Commercial |
$2,806.75
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.18
|
| Rate for Payer: Quartz Commercial |
$3,040.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,806.75
|
| Rate for Payer: The Alliance Commercial |
$2,338.96
|
| Rate for Payer: WEA Trust Commercial |
$2,572.86
|
| Rate for Payer: WPS Commercial |
$3,464.81
|
|
|
PLATE 2HH/4HS L +90 442.503
|
Facility
|
IP
|
$4,498.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,292.18 |
| Max. Negotiated Rate |
$4,303.69 |
| Rate for Payer: Aetna Commercial |
$4,210.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,023.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,479.30
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,303.69
|
| Rate for Payer: Health EOS Commercial |
$4,163.35
|
| Rate for Payer: HFN Commercial |
$4,303.69
|
| Rate for Payer: Multiplan Commercial |
$3,742.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,292.18
|
| Rate for Payer: Quartz Commercial |
$2,806.75
|
| Rate for Payer: WEA Trust Commercial |
$2,572.86
|
| Rate for Payer: WPS Commercial |
$3,464.81
|
|
|
PLATE 2 HOLE STRAIGHT 52020302
|
Facility
|
OP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5957650
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,150.24 |
| Max. Negotiated Rate |
$3,779.36 |
| Rate for Payer: Aetna Commercial |
$3,697.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,532.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,150.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,670.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,054.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,971.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,177.24
|
| Rate for Payer: Cash Price |
$1,185.00
|
| Rate for Payer: Cigna Commercial |
$3,779.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,298.90
|
| Rate for Payer: Health EOS Commercial |
$3,656.12
|
| Rate for Payer: HFN Commercial |
$3,779.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,081.00
|
| Rate for Payer: Multiplan Commercial |
$3,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,464.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,779.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,012.92
|
| Rate for Payer: Quartz Commercial |
$2,670.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,464.80
|
| Rate for Payer: The Alliance Commercial |
$2,054.00
|
| Rate for Payer: WEA Trust Commercial |
$2,259.40
|
| Rate for Payer: WPS Commercial |
$3,042.68
|
|
|
PLATE 2 HOLE STRAIGHT 52020302
|
Facility
|
IP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5957650
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,012.92 |
| Max. Negotiated Rate |
$3,779.36 |
| Rate for Payer: Aetna Commercial |
$3,697.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,532.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,177.24
|
| Rate for Payer: Cash Price |
$1,185.00
|
| Rate for Payer: Cigna Commercial |
$3,779.36
|
| Rate for Payer: Health EOS Commercial |
$3,656.12
|
| Rate for Payer: HFN Commercial |
$3,779.36
|
| Rate for Payer: Multiplan Commercial |
$3,286.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,779.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,012.92
|
| Rate for Payer: Quartz Commercial |
$2,464.80
|
| Rate for Payer: WEA Trust Commercial |
$2,259.40
|
| Rate for Payer: WPS Commercial |
$3,042.68
|
|
|
PLATE 3.5 3HL LAT DIST HUMERUS
|
Facility
|
IP
|
$6,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,488.21 |
| Max. Negotiated Rate |
$6,549.30 |
| Rate for Payer: Aetna Commercial |
$6,406.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,122.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,772.96
|
| Rate for Payer: Cash Price |
$2,053.50
|
| Rate for Payer: Cigna Commercial |
$6,549.30
|
| Rate for Payer: Health EOS Commercial |
$6,335.73
|
| Rate for Payer: HFN Commercial |
$6,549.30
|
| Rate for Payer: Multiplan Commercial |
$5,695.04
|
| Rate for Payer: Preferred Network Access Commercial |
$6,549.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,488.21
|
| Rate for Payer: Quartz Commercial |
$4,271.28
|
| Rate for Payer: WEA Trust Commercial |
$3,915.34
|
| Rate for Payer: WPS Commercial |
$5,272.70
|
|
|
PLATE 3.5 3HL LAT DIST HUMERUS
|
Facility
|
OP
|
$6,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,993.26 |
| Max. Negotiated Rate |
$6,549.30 |
| Rate for Payer: Aetna Commercial |
$6,406.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,122.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,993.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,627.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,559.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,417.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,772.96
|
| Rate for Payer: Cash Price |
$2,053.50
|
| Rate for Payer: Cigna Commercial |
$6,549.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,983.79
|
| Rate for Payer: Health EOS Commercial |
$6,335.73
|
| Rate for Payer: HFN Commercial |
$6,549.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,339.10
|
| Rate for Payer: Multiplan Commercial |
$5,695.04
|
| Rate for Payer: NAPHCARE Commercial |
$4,271.28
|
| Rate for Payer: Preferred Network Access Commercial |
$6,549.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,488.21
|
| Rate for Payer: Quartz Commercial |
$4,627.22
|
| Rate for Payer: Quartz Medicare Advantage |
$4,271.28
|
| Rate for Payer: The Alliance Commercial |
$3,559.40
|
| Rate for Payer: WEA Trust Commercial |
$3,915.34
|
| Rate for Payer: WPS Commercial |
$5,272.70
|
|
|
PLATE 3.5 3HL MED DIST HUMERUS
|
Facility
|
IP
|
$6,496.00
|
|
| Hospital Charge Code |
2966333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,310.36 |
| Max. Negotiated Rate |
$6,215.37 |
| Rate for Payer: Aetna Commercial |
$6,080.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,810.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,580.60
|
| Rate for Payer: Cash Price |
$1,948.80
|
| Rate for Payer: Cigna Commercial |
$6,215.37
|
| Rate for Payer: Health EOS Commercial |
$6,012.70
|
| Rate for Payer: HFN Commercial |
$6,215.37
|
| Rate for Payer: Multiplan Commercial |
$5,404.67
|
| Rate for Payer: Preferred Network Access Commercial |
$6,215.37
|
| Rate for Payer: Quartz Beloit One Network |
$3,310.36
|
| Rate for Payer: Quartz Commercial |
$4,053.50
|
| Rate for Payer: WEA Trust Commercial |
$3,715.71
|
| Rate for Payer: WPS Commercial |
$5,003.87
|
|
|
PLATE 3.5 3HL MED DIST HUMERUS
|
Facility
|
OP
|
$6,496.00
|
|
| Hospital Charge Code |
2966333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,891.64 |
| Max. Negotiated Rate |
$6,215.37 |
| Rate for Payer: Aetna Commercial |
$6,080.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,810.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,891.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,391.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,377.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,242.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,580.60
|
| Rate for Payer: Cash Price |
$1,948.80
|
| Rate for Payer: Cigna Commercial |
$6,215.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,780.67
|
| Rate for Payer: Health EOS Commercial |
$6,012.70
|
| Rate for Payer: HFN Commercial |
$6,215.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,066.88
|
| Rate for Payer: Multiplan Commercial |
$5,404.67
|
| Rate for Payer: NAPHCARE Commercial |
$4,053.50
|
| Rate for Payer: Preferred Network Access Commercial |
$6,215.37
|
| Rate for Payer: Quartz Beloit One Network |
$3,310.36
|
| Rate for Payer: Quartz Commercial |
$4,391.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,053.50
|
| Rate for Payer: The Alliance Commercial |
$3,377.92
|
| Rate for Payer: WEA Trust Commercial |
$3,715.71
|
| Rate for Payer: WPS Commercial |
$5,003.87
|
|
|
PLATE 3.5 3-HOLE RT LCP 241.262
|
Facility
|
OP
|
$9,004.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,621.96 |
| Max. Negotiated Rate |
$8,615.03 |
| Rate for Payer: Aetna Commercial |
$8,427.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,053.18
|
| Rate for Payer: Aetna Managed Medicare |
$2,621.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,086.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,682.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,494.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,963.00
|
| Rate for Payer: Cash Price |
$2,701.20
|
| Rate for Payer: Cigna Commercial |
$8,615.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,240.33
|
| Rate for Payer: Health EOS Commercial |
$8,334.10
|
| Rate for Payer: HFN Commercial |
$8,615.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,023.12
|
| Rate for Payer: Multiplan Commercial |
$7,491.33
|
| Rate for Payer: NAPHCARE Commercial |
$5,618.50
|
| Rate for Payer: Preferred Network Access Commercial |
$8,615.03
|
| Rate for Payer: Quartz Beloit One Network |
$4,588.44
|
| Rate for Payer: Quartz Commercial |
$6,086.70
|
| Rate for Payer: Quartz Medicare Advantage |
$5,618.50
|
| Rate for Payer: The Alliance Commercial |
$4,682.08
|
| Rate for Payer: WEA Trust Commercial |
$5,150.29
|
| Rate for Payer: WPS Commercial |
$6,935.78
|
|
|
PLATE 3.5 3-HOLE RT LCP 241.262
|
Facility
|
IP
|
$9,004.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,588.44 |
| Max. Negotiated Rate |
$8,615.03 |
| Rate for Payer: Aetna Commercial |
$8,427.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,053.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,963.00
|
| Rate for Payer: Cash Price |
$2,701.20
|
| Rate for Payer: Cigna Commercial |
$8,615.03
|
| Rate for Payer: Health EOS Commercial |
$8,334.10
|
| Rate for Payer: HFN Commercial |
$8,615.03
|
| Rate for Payer: Multiplan Commercial |
$7,491.33
|
| Rate for Payer: Preferred Network Access Commercial |
$8,615.03
|
| Rate for Payer: Quartz Beloit One Network |
$4,588.44
|
| Rate for Payer: Quartz Commercial |
$5,618.50
|
| Rate for Payer: WEA Trust Commercial |
$5,150.29
|
| Rate for Payer: WPS Commercial |
$6,935.78
|
|
|
PLATE 3.5 5HL RT MED DIST HUM
|
Facility
|
IP
|
$6,631.00
|
|
| Hospital Charge Code |
2966337
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,379.16 |
| Max. Negotiated Rate |
$6,344.54 |
| Rate for Payer: Aetna Commercial |
$6,206.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,930.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,655.01
|
| Rate for Payer: Cash Price |
$1,989.30
|
| Rate for Payer: Cigna Commercial |
$6,344.54
|
| Rate for Payer: Health EOS Commercial |
$6,137.65
|
| Rate for Payer: HFN Commercial |
$6,344.54
|
| Rate for Payer: Multiplan Commercial |
$5,516.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,344.54
|
| Rate for Payer: Quartz Beloit One Network |
$3,379.16
|
| Rate for Payer: Quartz Commercial |
$4,137.74
|
| Rate for Payer: WEA Trust Commercial |
$3,792.93
|
| Rate for Payer: WPS Commercial |
$5,107.86
|
|
|
PLATE 3.5 5HL RT MED DIST HUM
|
Facility
|
OP
|
$6,631.00
|
|
| Hospital Charge Code |
2966337
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,930.95 |
| Max. Negotiated Rate |
$6,344.54 |
| Rate for Payer: Aetna Commercial |
$6,206.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,930.77
|
| Rate for Payer: Aetna Managed Medicare |
$1,930.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,482.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,448.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,310.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,655.01
|
| Rate for Payer: Cash Price |
$1,989.30
|
| Rate for Payer: Cigna Commercial |
$6,344.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,859.24
|
| Rate for Payer: Health EOS Commercial |
$6,137.65
|
| Rate for Payer: HFN Commercial |
$6,344.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,172.18
|
| Rate for Payer: Multiplan Commercial |
$5,516.99
|
| Rate for Payer: NAPHCARE Commercial |
$4,137.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,344.54
|
| Rate for Payer: Quartz Beloit One Network |
$3,379.16
|
| Rate for Payer: Quartz Commercial |
$4,482.56
|
| Rate for Payer: Quartz Medicare Advantage |
$4,137.74
|
| Rate for Payer: The Alliance Commercial |
$3,448.12
|
| Rate for Payer: WEA Trust Commercial |
$3,792.93
|
| Rate for Payer: WPS Commercial |
$5,107.86
|
|
|
PLATE 3.5 7HL HOOK CLAVICLE 241.105S
|
Facility
|
OP
|
$8,595.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966339
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,502.86 |
| Max. Negotiated Rate |
$8,223.70 |
| Rate for Payer: Aetna Commercial |
$8,044.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,687.37
|
| Rate for Payer: Aetna Managed Medicare |
$2,502.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,810.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,469.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,290.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,737.56
|
| Rate for Payer: Cash Price |
$2,578.50
|
| Rate for Payer: Cigna Commercial |
$8,223.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,002.29
|
| Rate for Payer: Health EOS Commercial |
$7,955.53
|
| Rate for Payer: HFN Commercial |
$8,223.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,704.10
|
| Rate for Payer: Multiplan Commercial |
$7,151.04
|
| Rate for Payer: NAPHCARE Commercial |
$5,363.28
|
| Rate for Payer: Preferred Network Access Commercial |
$8,223.70
|
| Rate for Payer: Quartz Beloit One Network |
$4,380.01
|
| Rate for Payer: Quartz Commercial |
$5,810.22
|
| Rate for Payer: Quartz Medicare Advantage |
$5,363.28
|
| Rate for Payer: The Alliance Commercial |
$4,469.40
|
| Rate for Payer: WEA Trust Commercial |
$4,916.34
|
| Rate for Payer: WPS Commercial |
$6,620.73
|
|
|
PLATE 3.5 7HL HOOK CLAVICLE 241.105S
|
Facility
|
IP
|
$8,595.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966339
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,380.01 |
| Max. Negotiated Rate |
$8,223.70 |
| Rate for Payer: Aetna Commercial |
$8,044.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,687.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,737.56
|
| Rate for Payer: Cash Price |
$2,578.50
|
| Rate for Payer: Cigna Commercial |
$8,223.70
|
| Rate for Payer: Health EOS Commercial |
$7,955.53
|
| Rate for Payer: HFN Commercial |
$8,223.70
|
| Rate for Payer: Multiplan Commercial |
$7,151.04
|
| Rate for Payer: Preferred Network Access Commercial |
$8,223.70
|
| Rate for Payer: Quartz Beloit One Network |
$4,380.01
|
| Rate for Payer: Quartz Commercial |
$5,363.28
|
| Rate for Payer: WEA Trust Commercial |
$4,916.34
|
| Rate for Payer: WPS Commercial |
$6,620.73
|
|
|
PLATE 3.5 DISTAL HUMER 3HL LT
|
Facility
|
IP
|
$6,191.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,154.93 |
| Max. Negotiated Rate |
$5,923.55 |
| Rate for Payer: Aetna Commercial |
$5,794.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,537.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,412.48
|
| Rate for Payer: Cash Price |
$1,857.30
|
| Rate for Payer: Cigna Commercial |
$5,923.55
|
| Rate for Payer: Health EOS Commercial |
$5,730.39
|
| Rate for Payer: HFN Commercial |
$5,923.55
|
| Rate for Payer: Multiplan Commercial |
$5,150.91
|
| Rate for Payer: Preferred Network Access Commercial |
$5,923.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,154.93
|
| Rate for Payer: Quartz Commercial |
$3,863.18
|
| Rate for Payer: WEA Trust Commercial |
$3,541.25
|
| Rate for Payer: WPS Commercial |
$4,768.93
|
|
|
PLATE 3.5 DISTAL HUMER 3HL LT
|
Facility
|
OP
|
$6,191.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,802.82 |
| Max. Negotiated Rate |
$5,923.55 |
| Rate for Payer: Aetna Commercial |
$5,794.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,537.23
|
| Rate for Payer: Aetna Managed Medicare |
$1,802.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,185.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,219.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,090.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,412.48
|
| Rate for Payer: Cash Price |
$1,857.30
|
| Rate for Payer: Cigna Commercial |
$5,923.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,603.16
|
| Rate for Payer: Health EOS Commercial |
$5,730.39
|
| Rate for Payer: HFN Commercial |
$5,923.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,828.98
|
| Rate for Payer: Multiplan Commercial |
$5,150.91
|
| Rate for Payer: NAPHCARE Commercial |
$3,863.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,923.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,154.93
|
| Rate for Payer: Quartz Commercial |
$4,185.12
|
| Rate for Payer: Quartz Medicare Advantage |
$3,863.18
|
| Rate for Payer: The Alliance Commercial |
$3,219.32
|
| Rate for Payer: WEA Trust Commercial |
$3,541.25
|
| Rate for Payer: WPS Commercial |
$4,768.93
|
|
|
PLATE 3.5 LC-DCP 10HL 223.60
|
Facility
|
OP
|
$1,535.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966699
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$446.99 |
| Max. Negotiated Rate |
$1,468.69 |
| Rate for Payer: Aetna Commercial |
$1,436.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,372.90
|
| Rate for Payer: Aetna Managed Medicare |
$446.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,037.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$798.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$766.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.09
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,468.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$893.37
|
| Rate for Payer: Health EOS Commercial |
$1,420.80
|
| Rate for Payer: HFN Commercial |
$1,468.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,197.30
|
| Rate for Payer: Multiplan Commercial |
$1,277.12
|
| Rate for Payer: NAPHCARE Commercial |
$957.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,468.69
|
| Rate for Payer: Quartz Beloit One Network |
$782.24
|
| Rate for Payer: Quartz Commercial |
$1,037.66
|
| Rate for Payer: Quartz Medicare Advantage |
$957.84
|
| Rate for Payer: The Alliance Commercial |
$798.20
|
| Rate for Payer: WEA Trust Commercial |
$878.02
|
| Rate for Payer: WPS Commercial |
$1,182.41
|
|
|
PLATE 3.5 LC-DCP 10HL 223.60
|
Facility
|
IP
|
$1,535.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966699
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$782.24 |
| Max. Negotiated Rate |
$1,468.69 |
| Rate for Payer: Aetna Commercial |
$1,436.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,372.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.09
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,468.69
|
| Rate for Payer: Health EOS Commercial |
$1,420.80
|
| Rate for Payer: HFN Commercial |
$1,468.69
|
| Rate for Payer: Multiplan Commercial |
$1,277.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,468.69
|
| Rate for Payer: Quartz Beloit One Network |
$782.24
|
| Rate for Payer: Quartz Commercial |
$957.84
|
| Rate for Payer: WEA Trust Commercial |
$878.02
|
| Rate for Payer: WPS Commercial |
$1,182.41
|
|
|
PLATE 3.5 LC-DCP 12HL 223.62
|
Facility
|
IP
|
$1,660.00
|
|
| Hospital Charge Code |
2966700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.94 |
| Max. Negotiated Rate |
$1,588.29 |
| Rate for Payer: Aetna Commercial |
$1,553.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,484.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$914.99
|
| Rate for Payer: Cash Price |
$498.00
|
| Rate for Payer: Cigna Commercial |
$1,588.29
|
| Rate for Payer: Health EOS Commercial |
$1,536.50
|
| Rate for Payer: HFN Commercial |
$1,588.29
|
| Rate for Payer: Multiplan Commercial |
$1,381.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,588.29
|
| Rate for Payer: Quartz Beloit One Network |
$845.94
|
| Rate for Payer: Quartz Commercial |
$1,035.84
|
| Rate for Payer: WEA Trust Commercial |
$949.52
|
| Rate for Payer: WPS Commercial |
$1,278.70
|
|
