|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 3HL LT 02.118.401S
|
Facility
|
IP
|
$6,148.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5179147
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,012.52 |
| Max. Negotiated Rate |
$5,656.16 |
| Rate for Payer: Aetna Commercial |
$5,533.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,287.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,258.44
|
| Rate for Payer: Cash Price |
$1,844.40
|
| Rate for Payer: Cigna Commercial |
$5,656.16
|
| Rate for Payer: Health EOS Commercial |
$5,471.72
|
| Rate for Payer: HFN Commercial |
$5,656.16
|
| Rate for Payer: Multiplan Commercial |
$4,918.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,688.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,656.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,012.52
|
| Rate for Payer: Quartz Commercial |
$3,688.80
|
| Rate for Payer: WEA Trust Commercial |
$3,381.40
|
| Rate for Payer: WPS Commercial |
$4,553.82
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 3HL LT 02.118.401S
|
Facility
|
OP
|
$6,148.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5179147
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,721.44 |
| Max. Negotiated Rate |
$24,592.00 |
| Rate for Payer: Aetna Commercial |
$5,533.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,287.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,721.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,996.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,074.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,951.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,258.44
|
| Rate for Payer: Cash Price |
$1,844.40
|
| Rate for Payer: Cigna Commercial |
$5,656.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,440.42
|
| Rate for Payer: Health EOS Commercial |
$5,471.72
|
| Rate for Payer: HFN Commercial |
$5,656.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,611.00
|
| Rate for Payer: Multiplan Commercial |
$4,918.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,688.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,656.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,012.52
|
| Rate for Payer: Quartz Commercial |
$3,996.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,688.80
|
| Rate for Payer: The Alliance Commercial |
$24,592.00
|
| Rate for Payer: WEA Trust Commercial |
$3,381.40
|
| Rate for Payer: WPS Commercial |
$4,553.82
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 4HL RT 02.118.402
|
Facility
|
IP
|
$7,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,545.15 |
| Max. Negotiated Rate |
$6,656.20 |
| Rate for Payer: Aetna Commercial |
$6,511.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,222.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,834.55
|
| Rate for Payer: Cash Price |
$2,170.50
|
| Rate for Payer: Cigna Commercial |
$6,656.20
|
| Rate for Payer: Health EOS Commercial |
$6,439.15
|
| Rate for Payer: HFN Commercial |
$6,656.20
|
| Rate for Payer: Multiplan Commercial |
$5,788.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,341.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,656.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.15
|
| Rate for Payer: Quartz Commercial |
$4,341.00
|
| Rate for Payer: WEA Trust Commercial |
$3,979.25
|
| Rate for Payer: WPS Commercial |
$5,358.96
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 4HL RT 02.118.402
|
Facility
|
OP
|
$7,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,025.80 |
| Max. Negotiated Rate |
$28,940.00 |
| Rate for Payer: Aetna Commercial |
$6,511.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,222.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,025.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,702.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,617.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,472.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,834.55
|
| Rate for Payer: Cash Price |
$2,170.50
|
| Rate for Payer: Cigna Commercial |
$6,656.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,048.71
|
| Rate for Payer: Health EOS Commercial |
$6,439.15
|
| Rate for Payer: HFN Commercial |
$6,656.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,426.25
|
| Rate for Payer: Multiplan Commercial |
$5,788.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,341.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,656.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,545.15
|
| Rate for Payer: Quartz Commercial |
$4,702.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,341.00
|
| Rate for Payer: The Alliance Commercial |
$28,940.00
|
| Rate for Payer: WEA Trust Commercial |
$3,979.25
|
| Rate for Payer: WPS Commercial |
$5,358.96
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 6 HL LT 02.118.407
|
Facility
|
OP
|
$7,979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937359
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,234.12 |
| Max. Negotiated Rate |
$31,916.00 |
| Rate for Payer: Aetna Commercial |
$7,181.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,234.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,186.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,989.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,829.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.87
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,340.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,465.05
|
| Rate for Payer: Health EOS Commercial |
$7,101.31
|
| Rate for Payer: HFN Commercial |
$7,340.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,984.25
|
| Rate for Payer: Multiplan Commercial |
$6,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.71
|
| Rate for Payer: Quartz Commercial |
$5,186.35
|
| Rate for Payer: Quartz Medicare Advantage |
$4,787.40
|
| Rate for Payer: The Alliance Commercial |
$31,916.00
|
| Rate for Payer: WEA Trust Commercial |
$4,388.45
|
| Rate for Payer: WPS Commercial |
$5,910.05
|
|
|
PLATE 2.7 VA-LCP LATERAL DISTAL FIBULA 6 HL LT 02.118.407
|
Facility
|
IP
|
$7,979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937359
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,909.71 |
| Max. Negotiated Rate |
$7,340.68 |
| Rate for Payer: Aetna Commercial |
$7,181.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.87
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,340.68
|
| Rate for Payer: Health EOS Commercial |
$7,101.31
|
| Rate for Payer: HFN Commercial |
$7,340.68
|
| Rate for Payer: Multiplan Commercial |
$6,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.71
|
| Rate for Payer: Quartz Commercial |
$4,787.40
|
| Rate for Payer: WEA Trust Commercial |
$4,388.45
|
| Rate for Payer: WPS Commercial |
$5,910.05
|
|
|
PLATE 2-COLUMN RT VOL DIST RAD 02.111.640
|
Facility
|
OP
|
$6,518.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,825.04 |
| Max. Negotiated Rate |
$26,072.00 |
| Rate for Payer: Aetna Commercial |
$5,866.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,605.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,825.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,236.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,128.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,454.54
|
| Rate for Payer: Cash Price |
$1,955.40
|
| Rate for Payer: Cigna Commercial |
$5,996.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,647.47
|
| Rate for Payer: Health EOS Commercial |
$5,801.02
|
| Rate for Payer: HFN Commercial |
$5,996.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,888.50
|
| Rate for Payer: Multiplan Commercial |
$5,214.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,910.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,996.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,193.82
|
| Rate for Payer: Quartz Commercial |
$4,236.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,910.80
|
| Rate for Payer: The Alliance Commercial |
$26,072.00
|
| Rate for Payer: WEA Trust Commercial |
$3,584.90
|
| Rate for Payer: WPS Commercial |
$4,827.88
|
|
|
PLATE 2-COLUMN RT VOL DIST RAD 02.111.640
|
Facility
|
IP
|
$6,518.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,193.82 |
| Max. Negotiated Rate |
$5,996.56 |
| Rate for Payer: Aetna Commercial |
$5,866.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,605.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,454.54
|
| Rate for Payer: Cash Price |
$1,955.40
|
| Rate for Payer: Cigna Commercial |
$5,996.56
|
| Rate for Payer: Health EOS Commercial |
$5,801.02
|
| Rate for Payer: HFN Commercial |
$5,996.56
|
| Rate for Payer: Multiplan Commercial |
$5,214.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,910.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,996.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,193.82
|
| Rate for Payer: Quartz Commercial |
$3,910.80
|
| Rate for Payer: WEA Trust Commercial |
$3,584.90
|
| Rate for Payer: WPS Commercial |
$4,827.88
|
|
|
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 |
$2,094.75 |
| Max. Negotiated Rate |
$3,933.00 |
| Rate for Payer: Aetna Commercial |
$3,847.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,676.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,265.75
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$3,933.00
|
| Rate for Payer: Health EOS Commercial |
$3,804.75
|
| Rate for Payer: HFN Commercial |
$3,933.00
|
| Rate for Payer: Multiplan Commercial |
$3,420.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,565.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,933.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,094.75
|
| Rate for Payer: Quartz Commercial |
$2,565.00
|
| Rate for Payer: WEA Trust Commercial |
$2,351.25
|
| Rate for Payer: WPS Commercial |
$3,166.49
|
|
|
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 |
$1,197.00 |
| Max. Negotiated Rate |
$17,100.00 |
| Rate for Payer: Aetna Commercial |
$3,847.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,676.50
|
| Rate for Payer: Aetna Managed Medicare |
$1,197.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,778.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,137.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,052.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,265.75
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$3,933.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,392.29
|
| Rate for Payer: Health EOS Commercial |
$3,804.75
|
| Rate for Payer: HFN Commercial |
$3,933.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,206.25
|
| Rate for Payer: Multiplan Commercial |
$3,420.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,565.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,933.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,094.75
|
| Rate for Payer: Quartz Commercial |
$2,778.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,565.00
|
| Rate for Payer: The Alliance Commercial |
$17,100.00
|
| Rate for Payer: WEA Trust Commercial |
$2,351.25
|
| Rate for Payer: WPS Commercial |
$3,166.49
|
|
|
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 |
$2,094.75 |
| Max. Negotiated Rate |
$3,933.00 |
| Rate for Payer: Aetna Commercial |
$3,847.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,676.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,265.75
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$3,933.00
|
| Rate for Payer: Health EOS Commercial |
$3,804.75
|
| Rate for Payer: HFN Commercial |
$3,933.00
|
| Rate for Payer: Multiplan Commercial |
$3,420.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,565.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,933.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,094.75
|
| Rate for Payer: Quartz Commercial |
$2,565.00
|
| Rate for Payer: WEA Trust Commercial |
$2,351.25
|
| Rate for Payer: WPS Commercial |
$3,166.49
|
|
|
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 |
$1,197.00 |
| Max. Negotiated Rate |
$17,100.00 |
| Rate for Payer: Aetna Commercial |
$3,847.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,676.50
|
| Rate for Payer: Aetna Managed Medicare |
$1,197.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,778.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,137.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,052.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,265.75
|
| Rate for Payer: Cash Price |
$1,282.50
|
| Rate for Payer: Cigna Commercial |
$3,933.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,392.29
|
| Rate for Payer: Health EOS Commercial |
$3,804.75
|
| Rate for Payer: HFN Commercial |
$3,933.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,206.25
|
| Rate for Payer: Multiplan Commercial |
$3,420.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,565.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,933.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,094.75
|
| Rate for Payer: Quartz Commercial |
$2,778.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,565.00
|
| Rate for Payer: The Alliance Commercial |
$17,100.00
|
| Rate for Payer: WEA Trust Commercial |
$2,351.25
|
| Rate for Payer: WPS Commercial |
$3,166.49
|
|
|
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 |
$2,204.02 |
| Max. Negotiated Rate |
$4,138.16 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,698.80
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
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 |
$1,259.44 |
| Max. Negotiated Rate |
$17,992.00 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,249.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,159.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,517.08
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,373.50
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,923.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.80
|
| Rate for Payer: The Alliance Commercial |
$17,992.00
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
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 |
$1,259.44 |
| Max. Negotiated Rate |
$17,992.00 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,249.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,159.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,517.08
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,373.50
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,923.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.80
|
| Rate for Payer: The Alliance Commercial |
$17,992.00
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
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 |
$2,204.02 |
| Max. Negotiated Rate |
$4,138.16 |
| Rate for Payer: Aetna Commercial |
$4,048.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,868.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.94
|
| Rate for Payer: Cash Price |
$1,349.40
|
| Rate for Payer: Cigna Commercial |
$4,138.16
|
| Rate for Payer: Health EOS Commercial |
$4,003.22
|
| Rate for Payer: HFN Commercial |
$4,138.16
|
| Rate for Payer: Multiplan Commercial |
$3,598.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,138.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,204.02
|
| Rate for Payer: Quartz Commercial |
$2,698.80
|
| Rate for Payer: WEA Trust Commercial |
$2,473.90
|
| Rate for Payer: WPS Commercial |
$3,331.67
|
|
|
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 |
$1,106.00 |
| Max. Negotiated Rate |
$15,800.00 |
| Rate for Payer: Aetna Commercial |
$3,555.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,397.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,106.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,567.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,975.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,896.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,093.50
|
| Rate for Payer: Cash Price |
$1,185.00
|
| Rate for Payer: Cigna Commercial |
$3,634.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,210.42
|
| Rate for Payer: Health EOS Commercial |
$3,515.50
|
| Rate for Payer: HFN Commercial |
$3,634.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,962.50
|
| Rate for Payer: Multiplan Commercial |
$3,160.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,370.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,634.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,935.50
|
| Rate for Payer: Quartz Commercial |
$2,567.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,370.00
|
| Rate for Payer: The Alliance Commercial |
$15,800.00
|
| Rate for Payer: WEA Trust Commercial |
$2,172.50
|
| Rate for Payer: WPS Commercial |
$2,925.76
|
|
|
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 |
$1,935.50 |
| Max. Negotiated Rate |
$3,634.00 |
| Rate for Payer: Aetna Commercial |
$3,555.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,397.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,093.50
|
| Rate for Payer: Cash Price |
$1,185.00
|
| Rate for Payer: Cigna Commercial |
$3,634.00
|
| Rate for Payer: Health EOS Commercial |
$3,515.50
|
| Rate for Payer: HFN Commercial |
$3,634.00
|
| Rate for Payer: Multiplan Commercial |
$3,160.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,370.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,634.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,935.50
|
| Rate for Payer: Quartz Commercial |
$2,370.00
|
| Rate for Payer: WEA Trust Commercial |
$2,172.50
|
| Rate for Payer: WPS Commercial |
$2,925.76
|
|
|
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 |
$1,916.60 |
| Max. Negotiated Rate |
$27,380.00 |
| Rate for Payer: Aetna Commercial |
$6,160.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,886.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,916.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,449.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,422.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,285.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,627.85
|
| Rate for Payer: Cash Price |
$2,053.50
|
| Rate for Payer: Cigna Commercial |
$6,297.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,830.46
|
| Rate for Payer: Health EOS Commercial |
$6,092.05
|
| Rate for Payer: HFN Commercial |
$6,297.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,133.75
|
| Rate for Payer: Multiplan Commercial |
$5,476.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,107.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,297.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,354.05
|
| Rate for Payer: Quartz Commercial |
$4,449.25
|
| Rate for Payer: Quartz Medicare Advantage |
$4,107.00
|
| Rate for Payer: The Alliance Commercial |
$27,380.00
|
| Rate for Payer: WEA Trust Commercial |
$3,764.75
|
| Rate for Payer: WPS Commercial |
$5,070.09
|
|
|
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 |
$3,354.05 |
| Max. Negotiated Rate |
$6,297.40 |
| Rate for Payer: Aetna Commercial |
$6,160.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,886.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,627.85
|
| Rate for Payer: Cash Price |
$2,053.50
|
| Rate for Payer: Cigna Commercial |
$6,297.40
|
| Rate for Payer: Health EOS Commercial |
$6,092.05
|
| Rate for Payer: HFN Commercial |
$6,297.40
|
| Rate for Payer: Multiplan Commercial |
$5,476.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,107.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,297.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,354.05
|
| Rate for Payer: Quartz Commercial |
$4,107.00
|
| Rate for Payer: WEA Trust Commercial |
$3,764.75
|
| Rate for Payer: WPS Commercial |
$5,070.09
|
|
|
PLATE 3.5 3HL MED DIST HUMERUS
|
Facility
|
OP
|
$6,496.00
|
|
| Hospital Charge Code |
2966333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,818.88 |
| Max. Negotiated Rate |
$25,984.00 |
| Rate for Payer: Aetna Commercial |
$5,846.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,586.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,818.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,222.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,248.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,118.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,442.88
|
| Rate for Payer: Cash Price |
$1,948.80
|
| Rate for Payer: Cigna Commercial |
$5,976.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,635.16
|
| Rate for Payer: Health EOS Commercial |
$5,781.44
|
| Rate for Payer: HFN Commercial |
$5,976.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,872.00
|
| Rate for Payer: Multiplan Commercial |
$5,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,897.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,976.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,183.04
|
| Rate for Payer: Quartz Commercial |
$4,222.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,897.60
|
| Rate for Payer: The Alliance Commercial |
$25,984.00
|
| Rate for Payer: WEA Trust Commercial |
$3,572.80
|
| Rate for Payer: WPS Commercial |
$4,811.59
|
|
|
PLATE 3.5 3HL MED DIST HUMERUS
|
Facility
|
IP
|
$6,496.00
|
|
| Hospital Charge Code |
2966333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.04 |
| Max. Negotiated Rate |
$5,976.32 |
| Rate for Payer: Aetna Commercial |
$5,846.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,586.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,442.88
|
| Rate for Payer: Cash Price |
$1,948.80
|
| Rate for Payer: Cigna Commercial |
$5,976.32
|
| Rate for Payer: Health EOS Commercial |
$5,781.44
|
| Rate for Payer: HFN Commercial |
$5,976.32
|
| Rate for Payer: Multiplan Commercial |
$5,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,897.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,976.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,183.04
|
| Rate for Payer: Quartz Commercial |
$3,897.60
|
| Rate for Payer: WEA Trust Commercial |
$3,572.80
|
| Rate for Payer: WPS Commercial |
$4,811.59
|
|
|
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 |
$4,411.96 |
| Max. Negotiated Rate |
$8,283.68 |
| Rate for Payer: Aetna Commercial |
$8,103.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,743.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,772.12
|
| Rate for Payer: Cash Price |
$2,701.20
|
| Rate for Payer: Cigna Commercial |
$8,283.68
|
| Rate for Payer: Health EOS Commercial |
$8,013.56
|
| Rate for Payer: HFN Commercial |
$8,283.68
|
| Rate for Payer: Multiplan Commercial |
$7,203.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,402.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,283.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,411.96
|
| Rate for Payer: Quartz Commercial |
$5,402.40
|
| Rate for Payer: WEA Trust Commercial |
$4,952.20
|
| Rate for Payer: WPS Commercial |
$6,669.26
|
|
|
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 |
$2,521.12 |
| Max. Negotiated Rate |
$36,016.00 |
| Rate for Payer: Aetna Commercial |
$8,103.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,743.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,521.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,852.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,502.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,321.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,772.12
|
| Rate for Payer: Cash Price |
$2,701.20
|
| Rate for Payer: Cigna Commercial |
$8,283.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,038.64
|
| Rate for Payer: Health EOS Commercial |
$8,013.56
|
| Rate for Payer: HFN Commercial |
$8,283.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,753.00
|
| Rate for Payer: Multiplan Commercial |
$7,203.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,402.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,283.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,411.96
|
| Rate for Payer: Quartz Commercial |
$5,852.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,402.40
|
| Rate for Payer: The Alliance Commercial |
$36,016.00
|
| Rate for Payer: WEA Trust Commercial |
$4,952.20
|
| Rate for Payer: WPS Commercial |
$6,669.26
|
|
|
PLATE 3.5 5HL RT MED DIST HUM
|
Facility
|
IP
|
$6,631.00
|
|
| Hospital Charge Code |
2966337
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,249.19 |
| Max. Negotiated Rate |
$6,100.52 |
| Rate for Payer: Aetna Commercial |
$5,967.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,702.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,514.43
|
| Rate for Payer: Cash Price |
$1,989.30
|
| Rate for Payer: Cigna Commercial |
$6,100.52
|
| Rate for Payer: Health EOS Commercial |
$5,901.59
|
| Rate for Payer: HFN Commercial |
$6,100.52
|
| Rate for Payer: Multiplan Commercial |
$5,304.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,978.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,100.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,249.19
|
| Rate for Payer: Quartz Commercial |
$3,978.60
|
| Rate for Payer: WEA Trust Commercial |
$3,647.05
|
| Rate for Payer: WPS Commercial |
$4,911.58
|
|
