|
PLATE 2.4 ST-SH DST.RD 442.479
|
Facility
|
OP
|
$4,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,171.52 |
| Max. Negotiated Rate |
$16,736.00 |
| Rate for Payer: Aetna Commercial |
$3,765.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,598.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,171.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,719.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,092.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,008.32
|
| 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: Dean Health DHI/DHP/ASO |
$2,341.37
|
| Rate for Payer: Health EOS Commercial |
$3,723.76
|
| Rate for Payer: HFN Commercial |
$3,849.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,138.00
|
| 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 |
$2,719.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,510.40
|
| Rate for Payer: The Alliance Commercial |
$16,736.00
|
| Rate for Payer: WEA Trust Commercial |
$2,301.20
|
| Rate for Payer: WPS Commercial |
$3,099.09
|
|
|
PLATE 2.7/3.5 7HL RT FIBULA
|
Facility
|
IP
|
$6,012.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,945.88 |
| Max. Negotiated Rate |
$5,531.04 |
| Rate for Payer: Aetna Commercial |
$5,410.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,170.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,186.36
|
| Rate for Payer: Cash Price |
$1,803.60
|
| Rate for Payer: Cigna Commercial |
$5,531.04
|
| Rate for Payer: Health EOS Commercial |
$5,350.68
|
| Rate for Payer: HFN Commercial |
$5,531.04
|
| Rate for Payer: Multiplan Commercial |
$4,809.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,607.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,531.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,945.88
|
| Rate for Payer: Quartz Commercial |
$3,607.20
|
| Rate for Payer: WEA Trust Commercial |
$3,306.60
|
| Rate for Payer: WPS Commercial |
$4,453.09
|
|
|
PLATE 2.7/3.5 7HL RT FIBULA
|
Facility
|
OP
|
$6,012.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,683.36 |
| Max. Negotiated Rate |
$24,048.00 |
| Rate for Payer: Aetna Commercial |
$5,410.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,170.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,683.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,907.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,006.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,885.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,186.36
|
| Rate for Payer: Cash Price |
$1,803.60
|
| Rate for Payer: Cigna Commercial |
$5,531.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,364.32
|
| Rate for Payer: Health EOS Commercial |
$5,350.68
|
| Rate for Payer: HFN Commercial |
$5,531.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,509.00
|
| Rate for Payer: Multiplan Commercial |
$4,809.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,607.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,531.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,945.88
|
| Rate for Payer: Quartz Commercial |
$3,907.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,607.20
|
| Rate for Payer: The Alliance Commercial |
$24,048.00
|
| Rate for Payer: WEA Trust Commercial |
$3,306.60
|
| Rate for Payer: WPS Commercial |
$4,453.09
|
|
|
PLATE 2.7/3.5 FIBULA 3HL RT 02.112.136
|
Facility
|
IP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3259477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
PLATE 2.7/3.5 FIBULA 3HL RT 02.112.136
|
Facility
|
OP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3259477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 10HL 02.112.047
|
Facility
|
OP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4315757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,921.08 |
| Max. Negotiated Rate |
$27,444.00 |
| Rate for Payer: Aetna Commercial |
$6,174.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,900.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,921.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,459.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,293.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,636.33
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,312.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,839.42
|
| Rate for Payer: Health EOS Commercial |
$6,106.29
|
| Rate for Payer: HFN Commercial |
$6,312.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,145.75
|
| Rate for Payer: Multiplan Commercial |
$5,488.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,116.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,312.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,361.89
|
| Rate for Payer: Quartz Commercial |
$4,459.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,116.60
|
| Rate for Payer: The Alliance Commercial |
$27,444.00
|
| Rate for Payer: WEA Trust Commercial |
$3,773.55
|
| Rate for Payer: WPS Commercial |
$5,081.94
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 10HL 02.112.047
|
Facility
|
IP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4315757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,361.89 |
| Max. Negotiated Rate |
$6,312.12 |
| Rate for Payer: Aetna Commercial |
$6,174.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,900.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,636.33
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,312.12
|
| Rate for Payer: Health EOS Commercial |
$6,106.29
|
| Rate for Payer: HFN Commercial |
$6,312.12
|
| Rate for Payer: Multiplan Commercial |
$5,488.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,116.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,312.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,361.89
|
| Rate for Payer: Quartz Commercial |
$4,116.60
|
| Rate for Payer: WEA Trust Commercial |
$3,773.55
|
| Rate for Payer: WPS Commercial |
$5,081.94
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 9HL RT 02.112.046
|
Facility
|
IP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4340248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,361.89 |
| Max. Negotiated Rate |
$6,312.12 |
| Rate for Payer: Aetna Commercial |
$6,174.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,900.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,636.33
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,312.12
|
| Rate for Payer: Health EOS Commercial |
$6,106.29
|
| Rate for Payer: HFN Commercial |
$6,312.12
|
| Rate for Payer: Multiplan Commercial |
$5,488.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,116.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,312.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,361.89
|
| Rate for Payer: Quartz Commercial |
$4,116.60
|
| Rate for Payer: WEA Trust Commercial |
$3,773.55
|
| Rate for Payer: WPS Commercial |
$5,081.94
|
|
|
PLATE 2.7/3.5 LCP LATERAL ANTERIOR CLAVICLE 9HL RT 02.112.046
|
Facility
|
OP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4340248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,921.08 |
| Max. Negotiated Rate |
$27,444.00 |
| Rate for Payer: Aetna Commercial |
$6,174.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,900.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,921.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,459.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,293.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,636.33
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,312.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,839.42
|
| Rate for Payer: Health EOS Commercial |
$6,106.29
|
| Rate for Payer: HFN Commercial |
$6,312.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,145.75
|
| Rate for Payer: Multiplan Commercial |
$5,488.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,116.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,312.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,361.89
|
| Rate for Payer: Quartz Commercial |
$4,459.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,116.60
|
| Rate for Payer: The Alliance Commercial |
$27,444.00
|
| Rate for Payer: WEA Trust Commercial |
$3,773.55
|
| Rate for Payer: WPS Commercial |
$5,081.94
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 4HL RT 02.118.202
|
Facility
|
OP
|
$7,771.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4268743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,175.88 |
| Max. Negotiated Rate |
$31,084.00 |
| Rate for Payer: Aetna Commercial |
$6,993.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,683.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,175.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,051.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,885.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,730.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,118.63
|
| Rate for Payer: Cash Price |
$2,331.30
|
| Rate for Payer: Cigna Commercial |
$7,149.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,348.65
|
| Rate for Payer: Health EOS Commercial |
$6,916.19
|
| Rate for Payer: HFN Commercial |
$7,149.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,828.25
|
| Rate for Payer: Multiplan Commercial |
$6,216.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,662.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,149.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,807.79
|
| Rate for Payer: Quartz Commercial |
$5,051.15
|
| Rate for Payer: Quartz Medicare Advantage |
$4,662.60
|
| Rate for Payer: The Alliance Commercial |
$31,084.00
|
| Rate for Payer: WEA Trust Commercial |
$4,274.05
|
| Rate for Payer: WPS Commercial |
$5,755.98
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 4HL RT 02.118.202
|
Facility
|
IP
|
$7,771.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4268743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,807.79 |
| Max. Negotiated Rate |
$7,149.32 |
| Rate for Payer: Aetna Commercial |
$6,993.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,683.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,118.63
|
| Rate for Payer: Cash Price |
$2,331.30
|
| Rate for Payer: Cigna Commercial |
$7,149.32
|
| Rate for Payer: Health EOS Commercial |
$6,916.19
|
| Rate for Payer: HFN Commercial |
$7,149.32
|
| Rate for Payer: Multiplan Commercial |
$6,216.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,662.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,149.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,807.79
|
| Rate for Payer: Quartz Commercial |
$4,662.60
|
| Rate for Payer: WEA Trust Commercial |
$4,274.05
|
| Rate for Payer: WPS Commercial |
$5,755.98
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 6HL lT 02.118.205
|
Facility
|
OP
|
$7,789.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,180.92 |
| Max. Negotiated Rate |
$31,156.00 |
| Rate for Payer: Aetna Commercial |
$7,010.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,698.54
|
| Rate for Payer: Aetna Managed Medicare |
$2,180.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,062.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,894.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,738.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,128.17
|
| Rate for Payer: Cash Price |
$2,336.70
|
| Rate for Payer: Cigna Commercial |
$7,165.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,358.72
|
| Rate for Payer: Health EOS Commercial |
$6,932.21
|
| Rate for Payer: HFN Commercial |
$7,165.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,841.75
|
| Rate for Payer: Multiplan Commercial |
$6,231.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,673.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,165.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,816.61
|
| Rate for Payer: Quartz Commercial |
$5,062.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,673.40
|
| Rate for Payer: The Alliance Commercial |
$31,156.00
|
| Rate for Payer: WEA Trust Commercial |
$4,283.95
|
| Rate for Payer: WPS Commercial |
$5,769.31
|
|
|
PLATE 2.7/3.5MM ANTEREOLATERAL DISTAL TIBIA 6HL lT 02.118.205
|
Facility
|
IP
|
$7,789.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,816.61 |
| Max. Negotiated Rate |
$7,165.88 |
| Rate for Payer: Aetna Commercial |
$7,010.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,698.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,128.17
|
| Rate for Payer: Cash Price |
$2,336.70
|
| Rate for Payer: Cigna Commercial |
$7,165.88
|
| Rate for Payer: Health EOS Commercial |
$6,932.21
|
| Rate for Payer: HFN Commercial |
$7,165.88
|
| Rate for Payer: Multiplan Commercial |
$6,231.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,673.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,165.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,816.61
|
| Rate for Payer: Quartz Commercial |
$4,673.40
|
| Rate for Payer: WEA Trust Commercial |
$4,283.95
|
| Rate for Payer: WPS Commercial |
$5,769.31
|
|
|
PLATE 2.7 4HL LAT DIST FIBULA 02.112.139
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.06 |
| Max. Negotiated Rate |
$5,698.48 |
| Rate for Payer: Aetna Commercial |
$5,574.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,282.82
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,698.48
|
| Rate for Payer: Health EOS Commercial |
$5,512.66
|
| Rate for Payer: HFN Commercial |
$5,698.48
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,716.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,035.06
|
| Rate for Payer: Quartz Commercial |
$3,716.40
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
PLATE 2.7 4HL LAT DIST FIBULA 02.112.139
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,734.32 |
| Max. Negotiated Rate |
$24,776.00 |
| Rate for Payer: Aetna Commercial |
$5,574.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,326.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,734.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,026.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,097.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,973.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,282.82
|
| Rate for Payer: Cash Price |
$1,858.20
|
| Rate for Payer: Cigna Commercial |
$5,698.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,466.16
|
| Rate for Payer: Health EOS Commercial |
$5,512.66
|
| Rate for Payer: HFN Commercial |
$5,698.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,645.50
|
| Rate for Payer: Multiplan Commercial |
$4,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,716.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,035.06
|
| Rate for Payer: Quartz Commercial |
$4,026.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,716.40
|
| Rate for Payer: The Alliance Commercial |
$24,776.00
|
| Rate for Payer: WEA Trust Commercial |
$3,406.70
|
| Rate for Payer: WPS Commercial |
$4,587.90
|
|
|
PLATE 2.7 LATERAL DISTAL FIBULA 5 HOLE LEFT 02.118.405
|
Facility
|
OP
|
$7,594.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3323490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,126.32 |
| Max. Negotiated Rate |
$30,376.00 |
| Rate for Payer: Aetna Commercial |
$6,834.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,530.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,126.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,936.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,797.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,645.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,024.82
|
| Rate for Payer: Cash Price |
$2,278.20
|
| Rate for Payer: Cigna Commercial |
$6,986.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,249.60
|
| Rate for Payer: Health EOS Commercial |
$6,758.66
|
| Rate for Payer: HFN Commercial |
$6,986.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,695.50
|
| Rate for Payer: Multiplan Commercial |
$6,075.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,556.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,986.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,721.06
|
| Rate for Payer: Quartz Commercial |
$4,936.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,556.40
|
| Rate for Payer: The Alliance Commercial |
$30,376.00
|
| Rate for Payer: WEA Trust Commercial |
$4,176.70
|
| Rate for Payer: WPS Commercial |
$5,624.88
|
|
|
PLATE 2.7 LATERAL DISTAL FIBULA 5 HOLE LEFT 02.118.405
|
Facility
|
IP
|
$7,594.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3323490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,721.06 |
| Max. Negotiated Rate |
$6,986.48 |
| Rate for Payer: Aetna Commercial |
$6,834.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,530.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,024.82
|
| Rate for Payer: Cash Price |
$2,278.20
|
| Rate for Payer: Cigna Commercial |
$6,986.48
|
| Rate for Payer: Health EOS Commercial |
$6,758.66
|
| Rate for Payer: HFN Commercial |
$6,986.48
|
| Rate for Payer: Multiplan Commercial |
$6,075.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,556.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,986.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,721.06
|
| Rate for Payer: Quartz Commercial |
$4,556.40
|
| Rate for Payer: WEA Trust Commercial |
$4,176.70
|
| Rate for Payer: WPS Commercial |
$5,624.88
|
|
|
PLATE 2.7 LCP 4HL 249.680
|
Facility
|
IP
|
$5,358.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,625.42 |
| Max. Negotiated Rate |
$4,929.36 |
| Rate for Payer: Aetna Commercial |
$4,822.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,607.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,839.74
|
| Rate for Payer: Cash Price |
$1,607.40
|
| Rate for Payer: Cigna Commercial |
$4,929.36
|
| Rate for Payer: Health EOS Commercial |
$4,768.62
|
| Rate for Payer: HFN Commercial |
$4,929.36
|
| Rate for Payer: Multiplan Commercial |
$4,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,214.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,929.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,625.42
|
| Rate for Payer: Quartz Commercial |
$3,214.80
|
| Rate for Payer: WEA Trust Commercial |
$2,946.90
|
| Rate for Payer: WPS Commercial |
$3,968.67
|
|
|
PLATE 2.7 LCP 4HL 249.680
|
Facility
|
OP
|
$5,358.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.24 |
| Max. Negotiated Rate |
$21,432.00 |
| Rate for Payer: Aetna Commercial |
$4,822.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,607.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,500.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,482.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,679.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,571.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,839.74
|
| Rate for Payer: Cash Price |
$1,607.40
|
| Rate for Payer: Cigna Commercial |
$4,929.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,998.34
|
| Rate for Payer: Health EOS Commercial |
$4,768.62
|
| Rate for Payer: HFN Commercial |
$4,929.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,018.50
|
| Rate for Payer: Multiplan Commercial |
$4,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,214.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,929.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,625.42
|
| Rate for Payer: Quartz Commercial |
$3,482.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,214.80
|
| Rate for Payer: The Alliance Commercial |
$21,432.00
|
| Rate for Payer: WEA Trust Commercial |
$2,946.90
|
| Rate for Payer: WPS Commercial |
$3,968.67
|
|
|
PLATE 2.7 LCP 7HL 249.683
|
Facility
|
IP
|
$3,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,921.29 |
| Max. Negotiated Rate |
$3,607.32 |
| Rate for Payer: Aetna Commercial |
$3,528.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,372.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,078.13
|
| Rate for Payer: Cash Price |
$1,176.30
|
| Rate for Payer: Cigna Commercial |
$3,607.32
|
| Rate for Payer: Health EOS Commercial |
$3,489.69
|
| Rate for Payer: HFN Commercial |
$3,607.32
|
| Rate for Payer: Multiplan Commercial |
$3,136.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,352.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,607.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,921.29
|
| Rate for Payer: Quartz Commercial |
$2,352.60
|
| Rate for Payer: WEA Trust Commercial |
$2,156.55
|
| Rate for Payer: WPS Commercial |
$2,904.28
|
|
|
PLATE 2.7 LCP 7HL 249.683
|
Facility
|
OP
|
$3,921.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,097.88 |
| Max. Negotiated Rate |
$15,684.00 |
| Rate for Payer: Aetna Commercial |
$3,528.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,372.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,097.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,548.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,960.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,882.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,078.13
|
| Rate for Payer: Cash Price |
$1,176.30
|
| Rate for Payer: Cigna Commercial |
$3,607.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,194.19
|
| Rate for Payer: Health EOS Commercial |
$3,489.69
|
| Rate for Payer: HFN Commercial |
$3,607.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,940.75
|
| Rate for Payer: Multiplan Commercial |
$3,136.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,352.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,607.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,921.29
|
| Rate for Payer: Quartz Commercial |
$2,548.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,352.60
|
| Rate for Payer: The Alliance Commercial |
$15,684.00
|
| Rate for Payer: WEA Trust Commercial |
$2,156.55
|
| Rate for Payer: WPS Commercial |
$2,904.28
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY 6 HOLE 02.111.900
|
Facility
|
OP
|
$5,201.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,456.28 |
| Max. Negotiated Rate |
$20,804.00 |
| Rate for Payer: Aetna Commercial |
$4,680.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,472.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,456.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,380.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,600.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,496.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,756.53
|
| Rate for Payer: Cash Price |
$1,560.30
|
| Rate for Payer: Cigna Commercial |
$4,784.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,910.48
|
| Rate for Payer: Health EOS Commercial |
$4,628.89
|
| Rate for Payer: HFN Commercial |
$4,784.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,900.75
|
| Rate for Payer: Multiplan Commercial |
$4,160.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,120.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,784.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,548.49
|
| Rate for Payer: Quartz Commercial |
$3,380.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,120.60
|
| Rate for Payer: The Alliance Commercial |
$20,804.00
|
| Rate for Payer: WEA Trust Commercial |
$2,860.55
|
| Rate for Payer: WPS Commercial |
$3,852.38
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY 6 HOLE 02.111.900
|
Facility
|
IP
|
$5,201.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,548.49 |
| Max. Negotiated Rate |
$4,784.92 |
| Rate for Payer: Aetna Commercial |
$4,680.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,472.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,756.53
|
| Rate for Payer: Cash Price |
$1,560.30
|
| Rate for Payer: Cigna Commercial |
$4,784.92
|
| Rate for Payer: Health EOS Commercial |
$4,628.89
|
| Rate for Payer: HFN Commercial |
$4,784.92
|
| Rate for Payer: Multiplan Commercial |
$4,160.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,120.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,784.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,548.49
|
| Rate for Payer: Quartz Commercial |
$3,120.60
|
| Rate for Payer: WEA Trust Commercial |
$2,860.55
|
| Rate for Payer: WPS Commercial |
$3,852.38
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY TI 6 HOLE 04.111.900
|
Facility
|
IP
|
$5,593.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,740.57 |
| Max. Negotiated Rate |
$5,145.56 |
| Rate for Payer: Aetna Commercial |
$5,033.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,809.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,964.29
|
| Rate for Payer: Cash Price |
$1,677.90
|
| Rate for Payer: Cigna Commercial |
$5,145.56
|
| Rate for Payer: Health EOS Commercial |
$4,977.77
|
| Rate for Payer: HFN Commercial |
$5,145.56
|
| Rate for Payer: Multiplan Commercial |
$4,474.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,355.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,145.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,740.57
|
| Rate for Payer: Quartz Commercial |
$3,355.80
|
| Rate for Payer: WEA Trust Commercial |
$3,076.15
|
| Rate for Payer: WPS Commercial |
$4,142.74
|
|
|
PLATE 2.7MM LCP ULNA OSTEOTOMY TI 6 HOLE 04.111.900
|
Facility
|
OP
|
$5,593.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,566.04 |
| Max. Negotiated Rate |
$22,372.00 |
| Rate for Payer: Aetna Commercial |
$5,033.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,809.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,566.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,796.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,684.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,964.29
|
| Rate for Payer: Cash Price |
$1,677.90
|
| Rate for Payer: Cigna Commercial |
$5,145.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,129.84
|
| Rate for Payer: Health EOS Commercial |
$4,977.77
|
| Rate for Payer: HFN Commercial |
$5,145.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,194.75
|
| Rate for Payer: Multiplan Commercial |
$4,474.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,355.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,145.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,740.57
|
| Rate for Payer: Quartz Commercial |
$3,635.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,355.80
|
| Rate for Payer: The Alliance Commercial |
$22,372.00
|
| Rate for Payer: WEA Trust Commercial |
$3,076.15
|
| Rate for Payer: WPS Commercial |
$4,142.74
|
|
