|
PLATE 3.5MM METAPHYSEAL 11HOLE
|
Facility
|
OP
|
$6,283.00
|
|
| Hospital Charge Code |
2966342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,759.24 |
| Max. Negotiated Rate |
$25,132.00 |
| Rate for Payer: Aetna Commercial |
$5,654.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,403.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,759.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,083.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,141.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,015.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,329.99
|
| Rate for Payer: Cash Price |
$1,884.90
|
| Rate for Payer: Cigna Commercial |
$5,780.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,515.97
|
| Rate for Payer: Health EOS Commercial |
$5,591.87
|
| Rate for Payer: HFN Commercial |
$5,780.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,712.25
|
| Rate for Payer: Multiplan Commercial |
$5,026.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,769.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,780.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,078.67
|
| Rate for Payer: Quartz Commercial |
$4,083.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,769.80
|
| Rate for Payer: The Alliance Commercial |
$25,132.00
|
| Rate for Payer: WEA Trust Commercial |
$3,455.65
|
| Rate for Payer: WPS Commercial |
$4,653.82
|
|
|
PLATE 3.5MM METAPHYSEAL 11HOLE
|
Facility
|
IP
|
$6,283.00
|
|
| Hospital Charge Code |
2966342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,078.67 |
| Max. Negotiated Rate |
$5,780.36 |
| Rate for Payer: Aetna Commercial |
$5,654.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,403.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,329.99
|
| Rate for Payer: Cash Price |
$1,884.90
|
| Rate for Payer: Cigna Commercial |
$5,780.36
|
| Rate for Payer: Health EOS Commercial |
$5,591.87
|
| Rate for Payer: HFN Commercial |
$5,780.36
|
| Rate for Payer: Multiplan Commercial |
$5,026.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,769.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,780.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,078.67
|
| Rate for Payer: Quartz Commercial |
$3,769.80
|
| Rate for Payer: WEA Trust Commercial |
$3,455.65
|
| Rate for Payer: WPS Commercial |
$4,653.82
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 4HL LT 02.127.211
|
Facility
|
OP
|
$7,222.00
|
|
| Hospital Charge Code |
4462801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,022.16 |
| Max. Negotiated Rate |
$28,888.00 |
| Rate for Payer: Aetna Commercial |
$6,499.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,210.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,022.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,694.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,611.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,466.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,827.66
|
| Rate for Payer: Cash Price |
$2,166.60
|
| Rate for Payer: Cigna Commercial |
$6,644.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,041.43
|
| Rate for Payer: Health EOS Commercial |
$6,427.58
|
| Rate for Payer: HFN Commercial |
$6,644.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,416.50
|
| Rate for Payer: Multiplan Commercial |
$5,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,644.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.78
|
| Rate for Payer: Quartz Commercial |
$4,694.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,333.20
|
| Rate for Payer: The Alliance Commercial |
$28,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,972.10
|
| Rate for Payer: WPS Commercial |
$5,349.34
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 4HL LT 02.127.211
|
Facility
|
IP
|
$7,222.00
|
|
| Hospital Charge Code |
4462801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,538.78 |
| Max. Negotiated Rate |
$6,644.24 |
| Rate for Payer: Aetna Commercial |
$6,499.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,210.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,827.66
|
| Rate for Payer: Cash Price |
$2,166.60
|
| Rate for Payer: Cigna Commercial |
$6,644.24
|
| Rate for Payer: Health EOS Commercial |
$6,427.58
|
| Rate for Payer: HFN Commercial |
$6,644.24
|
| Rate for Payer: Multiplan Commercial |
$5,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,644.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.78
|
| Rate for Payer: Quartz Commercial |
$4,333.20
|
| Rate for Payer: WEA Trust Commercial |
$3,972.10
|
| Rate for Payer: WPS Commercial |
$5,349.34
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 4HL RT 02.127.210S
|
Facility
|
IP
|
$7,222.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5106922
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,538.78 |
| Max. Negotiated Rate |
$6,644.24 |
| Rate for Payer: Aetna Commercial |
$6,499.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,210.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,827.66
|
| Rate for Payer: Cash Price |
$2,166.60
|
| Rate for Payer: Cigna Commercial |
$6,644.24
|
| Rate for Payer: Health EOS Commercial |
$6,427.58
|
| Rate for Payer: HFN Commercial |
$6,644.24
|
| Rate for Payer: Multiplan Commercial |
$5,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,644.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.78
|
| Rate for Payer: Quartz Commercial |
$4,333.20
|
| Rate for Payer: WEA Trust Commercial |
$3,972.10
|
| Rate for Payer: WPS Commercial |
$5,349.34
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 4HL RT 02.127.210S
|
Facility
|
OP
|
$7,222.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5106922
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,022.16 |
| Max. Negotiated Rate |
$28,888.00 |
| Rate for Payer: Aetna Commercial |
$6,499.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,210.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,022.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,694.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,611.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,466.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,827.66
|
| Rate for Payer: Cash Price |
$2,166.60
|
| Rate for Payer: Cigna Commercial |
$6,644.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,041.43
|
| Rate for Payer: Health EOS Commercial |
$6,427.58
|
| Rate for Payer: HFN Commercial |
$6,644.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,416.50
|
| Rate for Payer: Multiplan Commercial |
$5,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,644.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,538.78
|
| Rate for Payer: Quartz Commercial |
$4,694.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,333.20
|
| Rate for Payer: The Alliance Commercial |
$28,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,972.10
|
| Rate for Payer: WPS Commercial |
$5,349.34
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 6HL LT 02.127.221S
|
Facility
|
IP
|
$7,533.00
|
|
| Hospital Charge Code |
5074826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,691.17 |
| Max. Negotiated Rate |
$6,930.36 |
| Rate for Payer: Aetna Commercial |
$6,779.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,478.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,992.49
|
| Rate for Payer: Cash Price |
$2,259.90
|
| Rate for Payer: Cigna Commercial |
$6,930.36
|
| Rate for Payer: Health EOS Commercial |
$6,704.37
|
| Rate for Payer: HFN Commercial |
$6,930.36
|
| Rate for Payer: Multiplan Commercial |
$6,026.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,519.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,930.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,691.17
|
| Rate for Payer: Quartz Commercial |
$4,519.80
|
| Rate for Payer: WEA Trust Commercial |
$4,143.15
|
| Rate for Payer: WPS Commercial |
$5,579.69
|
|
|
PLATE 3.5MM PROXIMAL TIBIA SM BEND 6HL LT 02.127.221S
|
Facility
|
OP
|
$7,533.00
|
|
| Hospital Charge Code |
5074826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,109.24 |
| Max. Negotiated Rate |
$30,132.00 |
| Rate for Payer: Aetna Commercial |
$6,779.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,478.38
|
| Rate for Payer: Aetna Managed Medicare |
$2,109.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,896.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,766.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,615.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,992.49
|
| Rate for Payer: Cash Price |
$2,259.90
|
| Rate for Payer: Cigna Commercial |
$6,930.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,215.47
|
| Rate for Payer: Health EOS Commercial |
$6,704.37
|
| Rate for Payer: HFN Commercial |
$6,930.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,649.75
|
| Rate for Payer: Multiplan Commercial |
$6,026.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,519.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,930.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,691.17
|
| Rate for Payer: Quartz Commercial |
$4,896.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,519.80
|
| Rate for Payer: The Alliance Commercial |
$30,132.00
|
| Rate for Payer: WEA Trust Commercial |
$4,143.15
|
| Rate for Payer: WPS Commercial |
$5,579.69
|
|
|
PLATE 3H 3H OBLIQ RT T 241.031
|
Facility
|
OP
|
$1,514.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$423.92 |
| Max. Negotiated Rate |
$6,056.00 |
| Rate for Payer: Aetna Commercial |
$1,362.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,302.04
|
| Rate for Payer: Aetna Managed Medicare |
$423.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$984.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$757.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$726.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$802.42
|
| Rate for Payer: Cash Price |
$454.20
|
| Rate for Payer: Cigna Commercial |
$1,392.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$847.23
|
| Rate for Payer: Health EOS Commercial |
$1,347.46
|
| Rate for Payer: HFN Commercial |
$1,392.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,135.50
|
| Rate for Payer: Multiplan Commercial |
$1,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$908.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,392.88
|
| Rate for Payer: Quartz Beloit One Network |
$741.86
|
| Rate for Payer: Quartz Commercial |
$984.10
|
| Rate for Payer: Quartz Medicare Advantage |
$908.40
|
| Rate for Payer: The Alliance Commercial |
$6,056.00
|
| Rate for Payer: WEA Trust Commercial |
$832.70
|
| Rate for Payer: WPS Commercial |
$1,121.42
|
|
|
PLATE 3H 3H OBLIQ RT T 241.031
|
Facility
|
IP
|
$1,514.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$741.86 |
| Max. Negotiated Rate |
$1,392.88 |
| Rate for Payer: Aetna Commercial |
$1,362.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,302.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$802.42
|
| Rate for Payer: Cash Price |
$454.20
|
| Rate for Payer: Cigna Commercial |
$1,392.88
|
| Rate for Payer: Health EOS Commercial |
$1,347.46
|
| Rate for Payer: HFN Commercial |
$1,392.88
|
| Rate for Payer: Multiplan Commercial |
$1,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$908.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,392.88
|
| Rate for Payer: Quartz Beloit One Network |
$741.86
|
| Rate for Payer: Quartz Commercial |
$908.40
|
| Rate for Payer: WEA Trust Commercial |
$832.70
|
| Rate for Payer: WPS Commercial |
$1,121.42
|
|
|
PLATE 3H 3H RT ANGLE T 241.131
|
Facility
|
OP
|
$1,324.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$370.72 |
| Max. Negotiated Rate |
$5,296.00 |
| Rate for Payer: Aetna Commercial |
$1,191.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,138.64
|
| Rate for Payer: Aetna Managed Medicare |
$370.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$860.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$662.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$635.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$701.72
|
| Rate for Payer: Cash Price |
$397.20
|
| Rate for Payer: Cigna Commercial |
$1,218.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$740.91
|
| Rate for Payer: Health EOS Commercial |
$1,178.36
|
| Rate for Payer: HFN Commercial |
$1,218.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.00
|
| Rate for Payer: Multiplan Commercial |
$1,059.20
|
| Rate for Payer: NAPHCARE Commercial |
$794.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.08
|
| Rate for Payer: Quartz Beloit One Network |
$648.76
|
| Rate for Payer: Quartz Commercial |
$860.60
|
| Rate for Payer: Quartz Medicare Advantage |
$794.40
|
| Rate for Payer: The Alliance Commercial |
$5,296.00
|
| Rate for Payer: WEA Trust Commercial |
$728.20
|
| Rate for Payer: WPS Commercial |
$980.69
|
|
|
PLATE 3H 3H RT ANGLE T 241.131
|
Facility
|
IP
|
$1,324.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$648.76 |
| Max. Negotiated Rate |
$1,218.08 |
| Rate for Payer: Aetna Commercial |
$1,191.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,138.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$701.72
|
| Rate for Payer: Cash Price |
$397.20
|
| Rate for Payer: Cigna Commercial |
$1,218.08
|
| Rate for Payer: Health EOS Commercial |
$1,178.36
|
| Rate for Payer: HFN Commercial |
$1,218.08
|
| Rate for Payer: Multiplan Commercial |
$1,059.20
|
| Rate for Payer: NAPHCARE Commercial |
$794.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.08
|
| Rate for Payer: Quartz Beloit One Network |
$648.76
|
| Rate for Payer: Quartz Commercial |
$794.40
|
| Rate for Payer: WEA Trust Commercial |
$728.20
|
| Rate for Payer: WPS Commercial |
$980.69
|
|
|
PLATE 3H 4H OBLIQ RT T 241.041
|
Facility
|
IP
|
$1,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$779.59 |
| Max. Negotiated Rate |
$1,463.72 |
| Rate for Payer: Aetna Commercial |
$1,431.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,368.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$843.23
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,463.72
|
| Rate for Payer: Health EOS Commercial |
$1,415.99
|
| Rate for Payer: HFN Commercial |
$1,463.72
|
| Rate for Payer: Multiplan Commercial |
$1,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$954.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,463.72
|
| Rate for Payer: Quartz Beloit One Network |
$779.59
|
| Rate for Payer: Quartz Commercial |
$954.60
|
| Rate for Payer: WEA Trust Commercial |
$875.05
|
| Rate for Payer: WPS Commercial |
$1,178.45
|
|
|
PLATE 3H 4H OBLIQ RT T 241.041
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.48 |
| Max. Negotiated Rate |
$6,364.00 |
| Rate for Payer: Aetna Commercial |
$1,431.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,368.26
|
| Rate for Payer: Aetna Managed Medicare |
$445.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,034.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$795.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$763.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$843.23
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,463.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$890.32
|
| Rate for Payer: Health EOS Commercial |
$1,415.99
|
| Rate for Payer: HFN Commercial |
$1,463.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,193.25
|
| Rate for Payer: Multiplan Commercial |
$1,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$954.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,463.72
|
| Rate for Payer: Quartz Beloit One Network |
$779.59
|
| Rate for Payer: Quartz Commercial |
$1,034.15
|
| Rate for Payer: Quartz Medicare Advantage |
$954.60
|
| Rate for Payer: The Alliance Commercial |
$6,364.00
|
| Rate for Payer: WEA Trust Commercial |
$875.05
|
| Rate for Payer: WPS Commercial |
$1,178.45
|
|
|
PLATE 3H 5H OBLIQ RT T 241.051
|
Facility
|
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$808.50 |
| Max. Negotiated Rate |
$1,518.00 |
| Rate for Payer: Aetna Commercial |
$1,485.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,419.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$874.50
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$1,518.00
|
| Rate for Payer: Health EOS Commercial |
$1,468.50
|
| Rate for Payer: HFN Commercial |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,320.00
|
| Rate for Payer: NAPHCARE Commercial |
$990.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,518.00
|
| Rate for Payer: Quartz Beloit One Network |
$808.50
|
| Rate for Payer: Quartz Commercial |
$990.00
|
| Rate for Payer: WEA Trust Commercial |
$907.50
|
| Rate for Payer: WPS Commercial |
$1,222.16
|
|
|
PLATE 3H 5H OBLIQ RT T 241.051
|
Facility
|
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.00 |
| Max. Negotiated Rate |
$6,600.00 |
| Rate for Payer: Aetna Commercial |
$1,485.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,419.00
|
| Rate for Payer: Aetna Managed Medicare |
$462.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,072.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$825.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$792.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$874.50
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$1,518.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$923.34
|
| Rate for Payer: Health EOS Commercial |
$1,468.50
|
| Rate for Payer: HFN Commercial |
$1,518.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,237.50
|
| Rate for Payer: Multiplan Commercial |
$1,320.00
|
| Rate for Payer: NAPHCARE Commercial |
$990.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,518.00
|
| Rate for Payer: Quartz Beloit One Network |
$808.50
|
| Rate for Payer: Quartz Commercial |
$1,072.50
|
| Rate for Payer: Quartz Medicare Advantage |
$990.00
|
| Rate for Payer: The Alliance Commercial |
$6,600.00
|
| Rate for Payer: WEA Trust Commercial |
$907.50
|
| Rate for Payer: WPS Commercial |
$1,222.16
|
|
|
PLATE 3H 5H RT ANGLE T 241.151
|
Facility
|
IP
|
$1,520.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$744.80 |
| Max. Negotiated Rate |
$1,398.40 |
| Rate for Payer: Aetna Commercial |
$1,368.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,307.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$805.60
|
| Rate for Payer: Cash Price |
$456.00
|
| Rate for Payer: Cigna Commercial |
$1,398.40
|
| Rate for Payer: Health EOS Commercial |
$1,352.80
|
| Rate for Payer: HFN Commercial |
$1,398.40
|
| Rate for Payer: Multiplan Commercial |
$1,216.00
|
| Rate for Payer: NAPHCARE Commercial |
$912.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,398.40
|
| Rate for Payer: Quartz Beloit One Network |
$744.80
|
| Rate for Payer: Quartz Commercial |
$912.00
|
| Rate for Payer: WEA Trust Commercial |
$836.00
|
| Rate for Payer: WPS Commercial |
$1,125.86
|
|
|
PLATE 3H 5H RT ANGLE T 241.151
|
Facility
|
OP
|
$1,520.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$425.60 |
| Max. Negotiated Rate |
$6,080.00 |
| Rate for Payer: Aetna Commercial |
$1,368.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,307.20
|
| Rate for Payer: Aetna Managed Medicare |
$425.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$988.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$760.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$729.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$805.60
|
| Rate for Payer: Cash Price |
$456.00
|
| Rate for Payer: Cigna Commercial |
$1,398.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$850.59
|
| Rate for Payer: Health EOS Commercial |
$1,352.80
|
| Rate for Payer: HFN Commercial |
$1,398.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,140.00
|
| Rate for Payer: Multiplan Commercial |
$1,216.00
|
| Rate for Payer: NAPHCARE Commercial |
$912.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,398.40
|
| Rate for Payer: Quartz Beloit One Network |
$744.80
|
| Rate for Payer: Quartz Commercial |
$988.00
|
| Rate for Payer: Quartz Medicare Advantage |
$912.00
|
| Rate for Payer: The Alliance Commercial |
$6,080.00
|
| Rate for Payer: WEA Trust Commercial |
$836.00
|
| Rate for Payer: WPS Commercial |
$1,125.86
|
|
|
PLATE 3H 7H OBLIQ RT T 241.071
|
Facility
|
OP
|
$1,867.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966711
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$522.76 |
| Max. Negotiated Rate |
$7,468.00 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Aetna Managed Medicare |
$522.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,213.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$933.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$896.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.51
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,717.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,044.77
|
| Rate for Payer: Health EOS Commercial |
$1,661.63
|
| Rate for Payer: HFN Commercial |
$1,717.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,400.25
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.64
|
| Rate for Payer: Quartz Beloit One Network |
$914.83
|
| Rate for Payer: Quartz Commercial |
$1,213.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,120.20
|
| Rate for Payer: The Alliance Commercial |
$7,468.00
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
PLATE 3H 7H OBLIQ RT T 241.071
|
Facility
|
IP
|
$1,867.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966711
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$914.83 |
| Max. Negotiated Rate |
$1,717.64 |
| Rate for Payer: Aetna Commercial |
$1,680.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,605.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$989.51
|
| Rate for Payer: Cash Price |
$560.10
|
| Rate for Payer: Cigna Commercial |
$1,717.64
|
| Rate for Payer: Health EOS Commercial |
$1,661.63
|
| Rate for Payer: HFN Commercial |
$1,717.64
|
| Rate for Payer: Multiplan Commercial |
$1,493.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,717.64
|
| Rate for Payer: Quartz Beloit One Network |
$914.83
|
| Rate for Payer: Quartz Commercial |
$1,120.20
|
| Rate for Payer: WEA Trust Commercial |
$1,026.85
|
| Rate for Payer: WPS Commercial |
$1,382.89
|
|
|
PLATE 3H 7H RT ANGLE T 241.171
|
Facility
|
OP
|
$2,225.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$623.00 |
| Max. Negotiated Rate |
$8,900.00 |
| Rate for Payer: Aetna Commercial |
$2,002.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,913.50
|
| Rate for Payer: Aetna Managed Medicare |
$623.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,446.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,112.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,068.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,179.25
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$2,047.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,245.11
|
| Rate for Payer: Health EOS Commercial |
$1,980.25
|
| Rate for Payer: HFN Commercial |
$2,047.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,668.75
|
| Rate for Payer: Multiplan Commercial |
$1,780.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,335.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,047.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,090.25
|
| Rate for Payer: Quartz Commercial |
$1,446.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,335.00
|
| Rate for Payer: The Alliance Commercial |
$8,900.00
|
| Rate for Payer: WEA Trust Commercial |
$1,223.75
|
| Rate for Payer: WPS Commercial |
$1,648.06
|
|
|
PLATE 3H 7H RT ANGLE T 241.171
|
Facility
|
IP
|
$2,225.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.25 |
| Max. Negotiated Rate |
$2,047.00 |
| Rate for Payer: Aetna Commercial |
$2,002.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,913.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,179.25
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$2,047.00
|
| Rate for Payer: Health EOS Commercial |
$1,980.25
|
| Rate for Payer: HFN Commercial |
$2,047.00
|
| Rate for Payer: Multiplan Commercial |
$1,780.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,335.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,047.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,090.25
|
| Rate for Payer: Quartz Commercial |
$1,335.00
|
| Rate for Payer: WEA Trust Commercial |
$1,223.75
|
| Rate for Payer: WPS Commercial |
$1,648.06
|
|
|
PLATE 3HH/3HS L +20 442.508
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966713
|
|
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 3HH/3HS L +20 442.508
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966713
|
|
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 3HH/3HS L -20 442.511
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2990951
|
|
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
|
|
