|
PLATE 4H 6H RT ANGLE T 241.161
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$201.60 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$648.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.20
|
| Rate for Payer: Aetna Managed Medicare |
$201.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$468.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$360.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$345.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.60
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$662.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$402.91
|
| Rate for Payer: Health EOS Commercial |
$640.80
|
| Rate for Payer: HFN Commercial |
$662.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$540.00
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: NAPHCARE Commercial |
$432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$662.40
|
| Rate for Payer: Quartz Beloit One Network |
$352.80
|
| Rate for Payer: Quartz Commercial |
$468.00
|
| Rate for Payer: Quartz Medicare Advantage |
$432.00
|
| Rate for Payer: The Alliance Commercial |
$2,880.00
|
| Rate for Payer: WEA Trust Commercial |
$396.00
|
| Rate for Payer: WPS Commercial |
$533.30
|
|
|
PLATE 4H 6H RT ANGLE T 241.161
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.80 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Aetna Commercial |
$648.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.60
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$662.40
|
| Rate for Payer: Health EOS Commercial |
$640.80
|
| Rate for Payer: HFN Commercial |
$662.40
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: NAPHCARE Commercial |
$432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$662.40
|
| Rate for Payer: Quartz Beloit One Network |
$352.80
|
| Rate for Payer: Quartz Commercial |
$432.00
|
| Rate for Payer: WEA Trust Commercial |
$396.00
|
| Rate for Payer: WPS Commercial |
$533.30
|
|
|
PLATE 4HL 3.5 RT M/D/T 239.900
|
Facility
|
OP
|
$7,307.00
|
|
| Hospital Charge Code |
2966725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,045.96 |
| Max. Negotiated Rate |
$29,228.00 |
| Rate for Payer: Aetna Commercial |
$6,576.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,284.02
|
| Rate for Payer: Aetna Managed Medicare |
$2,045.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,749.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,653.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,507.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,872.71
|
| Rate for Payer: Cash Price |
$2,192.10
|
| Rate for Payer: Cigna Commercial |
$6,722.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,089.00
|
| Rate for Payer: Health EOS Commercial |
$6,503.23
|
| Rate for Payer: HFN Commercial |
$6,722.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,480.25
|
| Rate for Payer: Multiplan Commercial |
$5,845.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,384.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,722.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,580.43
|
| Rate for Payer: Quartz Commercial |
$4,749.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,384.20
|
| Rate for Payer: The Alliance Commercial |
$29,228.00
|
| Rate for Payer: WEA Trust Commercial |
$4,018.85
|
| Rate for Payer: WPS Commercial |
$5,412.29
|
|
|
PLATE 4HL 3.5 RT M/D/T 239.900
|
Facility
|
IP
|
$7,307.00
|
|
| Hospital Charge Code |
2966725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,580.43 |
| Max. Negotiated Rate |
$6,722.44 |
| Rate for Payer: Aetna Commercial |
$6,576.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,284.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,872.71
|
| Rate for Payer: Cash Price |
$2,192.10
|
| Rate for Payer: Cigna Commercial |
$6,722.44
|
| Rate for Payer: Health EOS Commercial |
$6,503.23
|
| Rate for Payer: HFN Commercial |
$6,722.44
|
| Rate for Payer: Multiplan Commercial |
$5,845.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,384.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,722.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,580.43
|
| Rate for Payer: Quartz Commercial |
$4,384.20
|
| Rate for Payer: WEA Trust Commercial |
$4,018.85
|
| Rate for Payer: WPS Commercial |
$5,412.29
|
|
|
PLATE 4 HL/78MM DHS STANDARD
|
Facility
|
OP
|
$4,951.00
|
|
| Hospital Charge Code |
2966343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.28 |
| Max. Negotiated Rate |
$19,804.00 |
| Rate for Payer: Aetna Commercial |
$4,455.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,257.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,386.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,218.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,475.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,376.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,624.03
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,554.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,770.58
|
| Rate for Payer: Health EOS Commercial |
$4,406.39
|
| Rate for Payer: HFN Commercial |
$4,554.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,713.25
|
| Rate for Payer: Multiplan Commercial |
$3,960.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,970.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,554.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,425.99
|
| Rate for Payer: Quartz Commercial |
$3,218.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,970.60
|
| Rate for Payer: The Alliance Commercial |
$19,804.00
|
| Rate for Payer: WEA Trust Commercial |
$2,723.05
|
| Rate for Payer: WPS Commercial |
$3,667.21
|
|
|
PLATE 4 HL/78MM DHS STANDARD
|
Facility
|
IP
|
$4,951.00
|
|
| Hospital Charge Code |
2966343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,425.99 |
| Max. Negotiated Rate |
$4,554.92 |
| Rate for Payer: Aetna Commercial |
$4,455.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,257.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,624.03
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,554.92
|
| Rate for Payer: Health EOS Commercial |
$4,406.39
|
| Rate for Payer: HFN Commercial |
$4,554.92
|
| Rate for Payer: Multiplan Commercial |
$3,960.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,970.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,554.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,425.99
|
| Rate for Payer: Quartz Commercial |
$2,970.60
|
| Rate for Payer: WEA Trust Commercial |
$2,723.05
|
| Rate for Payer: WPS Commercial |
$3,667.21
|
|
|
PLATE 4HL/RT DISTAL FIBULA 02.112.138
|
Facility
|
IP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966348
|
|
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 4HL/RT DISTAL FIBULA 02.112.138
|
Facility
|
OP
|
$6,194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966348
|
|
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 4H LT MED/DIS/TI 239.901
|
Facility
|
OP
|
$5,084.00
|
|
| Hospital Charge Code |
2966723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,423.52 |
| Max. Negotiated Rate |
$20,336.00 |
| Rate for Payer: Aetna Commercial |
$4,575.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,372.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,423.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,304.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,440.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,694.52
|
| Rate for Payer: Cash Price |
$1,525.20
|
| Rate for Payer: Cigna Commercial |
$4,677.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,845.01
|
| Rate for Payer: Health EOS Commercial |
$4,524.76
|
| Rate for Payer: HFN Commercial |
$4,677.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,813.00
|
| Rate for Payer: Multiplan Commercial |
$4,067.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,050.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,677.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,491.16
|
| Rate for Payer: Quartz Commercial |
$3,304.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,050.40
|
| Rate for Payer: The Alliance Commercial |
$20,336.00
|
| Rate for Payer: WEA Trust Commercial |
$2,796.20
|
| Rate for Payer: WPS Commercial |
$3,765.72
|
|
|
PLATE 4H LT MED/DIS/TI 239.901
|
Facility
|
IP
|
$5,084.00
|
|
| Hospital Charge Code |
2966723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,491.16 |
| Max. Negotiated Rate |
$4,677.28 |
| Rate for Payer: Aetna Commercial |
$4,575.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,372.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,694.52
|
| Rate for Payer: Cash Price |
$1,525.20
|
| Rate for Payer: Cigna Commercial |
$4,677.28
|
| Rate for Payer: Health EOS Commercial |
$4,524.76
|
| Rate for Payer: HFN Commercial |
$4,677.28
|
| Rate for Payer: Multiplan Commercial |
$4,067.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,050.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,677.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,491.16
|
| Rate for Payer: Quartz Commercial |
$3,050.40
|
| Rate for Payer: WEA Trust Commercial |
$2,796.20
|
| Rate for Payer: WPS Commercial |
$3,765.72
|
|
|
PLATE 4H LT PROX/TIB 240.037
|
Facility
|
IP
|
$4,572.00
|
|
| Hospital Charge Code |
2966722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,240.28 |
| Max. Negotiated Rate |
$4,206.24 |
| Rate for Payer: Aetna Commercial |
$4,114.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,931.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,423.16
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,206.24
|
| Rate for Payer: Health EOS Commercial |
$4,069.08
|
| Rate for Payer: HFN Commercial |
$4,206.24
|
| Rate for Payer: Multiplan Commercial |
$3,657.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,743.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,206.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,240.28
|
| Rate for Payer: Quartz Commercial |
$2,743.20
|
| Rate for Payer: WEA Trust Commercial |
$2,514.60
|
| Rate for Payer: WPS Commercial |
$3,386.48
|
|
|
PLATE 4H LT PROX/TIB 240.037
|
Facility
|
OP
|
$4,572.00
|
|
| Hospital Charge Code |
2966722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,280.16 |
| Max. Negotiated Rate |
$18,288.00 |
| Rate for Payer: Aetna Commercial |
$4,114.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,931.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,280.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,971.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,286.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,194.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,423.16
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,206.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,558.49
|
| Rate for Payer: Health EOS Commercial |
$4,069.08
|
| Rate for Payer: HFN Commercial |
$4,206.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,429.00
|
| Rate for Payer: Multiplan Commercial |
$3,657.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,743.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,206.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,240.28
|
| Rate for Payer: Quartz Commercial |
$2,971.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,743.20
|
| Rate for Payer: The Alliance Commercial |
$18,288.00
|
| Rate for Payer: WEA Trust Commercial |
$2,514.60
|
| Rate for Payer: WPS Commercial |
$3,386.48
|
|
|
PLATE 4 HOLE LEFT
|
Facility
|
IP
|
$6,251.00
|
|
| Hospital Charge Code |
2966344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,062.99 |
| Max. Negotiated Rate |
$5,750.92 |
| Rate for Payer: Aetna Commercial |
$5,625.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,375.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,313.03
|
| Rate for Payer: Cash Price |
$1,875.30
|
| Rate for Payer: Cigna Commercial |
$5,750.92
|
| Rate for Payer: Health EOS Commercial |
$5,563.39
|
| Rate for Payer: HFN Commercial |
$5,750.92
|
| Rate for Payer: Multiplan Commercial |
$5,000.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,750.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,750.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,062.99
|
| Rate for Payer: Quartz Commercial |
$3,750.60
|
| Rate for Payer: WEA Trust Commercial |
$3,438.05
|
| Rate for Payer: WPS Commercial |
$4,630.12
|
|
|
PLATE 4 HOLE LEFT
|
Facility
|
OP
|
$6,251.00
|
|
| Hospital Charge Code |
2966344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,750.28 |
| Max. Negotiated Rate |
$25,004.00 |
| Rate for Payer: Aetna Commercial |
$5,625.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,375.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,750.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,063.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,125.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,000.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,313.03
|
| Rate for Payer: Cash Price |
$1,875.30
|
| Rate for Payer: Cigna Commercial |
$5,750.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,498.06
|
| Rate for Payer: Health EOS Commercial |
$5,563.39
|
| Rate for Payer: HFN Commercial |
$5,750.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,688.25
|
| Rate for Payer: Multiplan Commercial |
$5,000.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,750.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,750.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,062.99
|
| Rate for Payer: Quartz Commercial |
$4,063.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3,750.60
|
| Rate for Payer: The Alliance Commercial |
$25,004.00
|
| Rate for Payer: WEA Trust Commercial |
$3,438.05
|
| Rate for Payer: WPS Commercial |
$4,630.12
|
|
|
PLATE 4 HOLE OLECRANON
|
Facility
|
IP
|
$8,637.00
|
|
| Hospital Charge Code |
2966345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,232.13 |
| Max. Negotiated Rate |
$7,946.04 |
| Rate for Payer: Aetna Commercial |
$7,773.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,427.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,577.61
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cigna Commercial |
$7,946.04
|
| Rate for Payer: Health EOS Commercial |
$7,686.93
|
| Rate for Payer: HFN Commercial |
$7,946.04
|
| Rate for Payer: Multiplan Commercial |
$6,909.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,182.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,946.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,232.13
|
| Rate for Payer: Quartz Commercial |
$5,182.20
|
| Rate for Payer: WEA Trust Commercial |
$4,750.35
|
| Rate for Payer: WPS Commercial |
$6,397.43
|
|
|
PLATE 4 HOLE OLECRANON
|
Facility
|
OP
|
$8,637.00
|
|
| Hospital Charge Code |
2966345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,418.36 |
| Max. Negotiated Rate |
$34,548.00 |
| Rate for Payer: Aetna Commercial |
$7,773.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,427.82
|
| Rate for Payer: Aetna Managed Medicare |
$2,418.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,614.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,318.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,145.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,577.61
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cigna Commercial |
$7,946.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,833.27
|
| Rate for Payer: Health EOS Commercial |
$7,686.93
|
| Rate for Payer: HFN Commercial |
$7,946.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,477.75
|
| Rate for Payer: Multiplan Commercial |
$6,909.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,182.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,946.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,232.13
|
| Rate for Payer: Quartz Commercial |
$5,614.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,182.20
|
| Rate for Payer: The Alliance Commercial |
$34,548.00
|
| Rate for Payer: WEA Trust Commercial |
$4,750.35
|
| Rate for Payer: WPS Commercial |
$6,397.43
|
|
|
PLATE 4H RT PROX/TIB 240.036
|
Facility
|
OP
|
$4,572.00
|
|
| Hospital Charge Code |
2966724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,280.16 |
| Max. Negotiated Rate |
$18,288.00 |
| Rate for Payer: Aetna Commercial |
$4,114.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,931.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,280.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,971.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,286.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,194.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,423.16
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,206.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,558.49
|
| Rate for Payer: Health EOS Commercial |
$4,069.08
|
| Rate for Payer: HFN Commercial |
$4,206.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,429.00
|
| Rate for Payer: Multiplan Commercial |
$3,657.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,743.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,206.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,240.28
|
| Rate for Payer: Quartz Commercial |
$2,971.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,743.20
|
| Rate for Payer: The Alliance Commercial |
$18,288.00
|
| Rate for Payer: WEA Trust Commercial |
$2,514.60
|
| Rate for Payer: WPS Commercial |
$3,386.48
|
|
|
PLATE 4H RT PROX/TIB 240.036
|
Facility
|
IP
|
$4,572.00
|
|
| Hospital Charge Code |
2966724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,240.28 |
| Max. Negotiated Rate |
$4,206.24 |
| Rate for Payer: Aetna Commercial |
$4,114.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,931.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,423.16
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,206.24
|
| Rate for Payer: Health EOS Commercial |
$4,069.08
|
| Rate for Payer: HFN Commercial |
$4,206.24
|
| Rate for Payer: Multiplan Commercial |
$3,657.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,743.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,206.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,240.28
|
| Rate for Payer: Quartz Commercial |
$2,743.20
|
| Rate for Payer: WEA Trust Commercial |
$2,514.60
|
| Rate for Payer: WPS Commercial |
$3,386.48
|
|
|
PLATE 5H 3.5 LCP 223.551
|
Facility
|
OP
|
$1,249.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$349.72 |
| Max. Negotiated Rate |
$4,996.00 |
| Rate for Payer: Aetna Commercial |
$1,124.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,074.14
|
| Rate for Payer: Aetna Managed Medicare |
$349.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$811.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$624.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$599.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$661.97
|
| Rate for Payer: Cash Price |
$374.70
|
| Rate for Payer: Cigna Commercial |
$1,149.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$698.94
|
| Rate for Payer: Health EOS Commercial |
$1,111.61
|
| Rate for Payer: HFN Commercial |
$1,149.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$936.75
|
| Rate for Payer: Multiplan Commercial |
$999.20
|
| Rate for Payer: NAPHCARE Commercial |
$749.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,149.08
|
| Rate for Payer: Quartz Beloit One Network |
$612.01
|
| Rate for Payer: Quartz Commercial |
$811.85
|
| Rate for Payer: Quartz Medicare Advantage |
$749.40
|
| Rate for Payer: The Alliance Commercial |
$4,996.00
|
| Rate for Payer: WEA Trust Commercial |
$686.95
|
| Rate for Payer: WPS Commercial |
$925.13
|
|
|
PLATE 5H 3.5 LCP 223.551
|
Facility
|
IP
|
$1,249.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$612.01 |
| Max. Negotiated Rate |
$1,149.08 |
| Rate for Payer: Aetna Commercial |
$1,124.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,074.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$661.97
|
| Rate for Payer: Cash Price |
$374.70
|
| Rate for Payer: Cigna Commercial |
$1,149.08
|
| Rate for Payer: Health EOS Commercial |
$1,111.61
|
| Rate for Payer: HFN Commercial |
$1,149.08
|
| Rate for Payer: Multiplan Commercial |
$999.20
|
| Rate for Payer: NAPHCARE Commercial |
$749.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,149.08
|
| Rate for Payer: Quartz Beloit One Network |
$612.01
|
| Rate for Payer: Quartz Commercial |
$749.40
|
| Rate for Payer: WEA Trust Commercial |
$686.95
|
| Rate for Payer: WPS Commercial |
$925.13
|
|
|
PLATE 5H 3.5 LCP RECON 245.051
|
Facility
|
IP
|
$1,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$904.05 |
| Max. Negotiated Rate |
$1,697.40 |
| Rate for Payer: Aetna Commercial |
$1,660.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,586.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$977.85
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cigna Commercial |
$1,697.40
|
| Rate for Payer: Health EOS Commercial |
$1,642.05
|
| Rate for Payer: HFN Commercial |
$1,697.40
|
| Rate for Payer: Multiplan Commercial |
$1,476.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,697.40
|
| Rate for Payer: Quartz Beloit One Network |
$904.05
|
| Rate for Payer: Quartz Commercial |
$1,107.00
|
| Rate for Payer: WEA Trust Commercial |
$1,014.75
|
| Rate for Payer: WPS Commercial |
$1,366.59
|
|
|
PLATE 5H 3.5 LCP RECON 245.051
|
Facility
|
OP
|
$1,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$516.60 |
| Max. Negotiated Rate |
$7,380.00 |
| Rate for Payer: Aetna Commercial |
$1,660.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,586.70
|
| Rate for Payer: Aetna Managed Medicare |
$516.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,199.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$922.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$885.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$977.85
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cigna Commercial |
$1,697.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,032.46
|
| Rate for Payer: Health EOS Commercial |
$1,642.05
|
| Rate for Payer: HFN Commercial |
$1,697.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,383.75
|
| Rate for Payer: Multiplan Commercial |
$1,476.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,697.40
|
| Rate for Payer: Quartz Beloit One Network |
$904.05
|
| Rate for Payer: Quartz Commercial |
$1,199.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,107.00
|
| Rate for Payer: The Alliance Commercial |
$7,380.00
|
| Rate for Payer: WEA Trust Commercial |
$1,014.75
|
| Rate for Payer: WPS Commercial |
$1,366.59
|
|
|
PLATE 5 HL DISTAL FEMUR RT
|
Facility
|
IP
|
$2,924.00
|
|
| Hospital Charge Code |
2966349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,432.76 |
| Max. Negotiated Rate |
$2,690.08 |
| Rate for Payer: Aetna Commercial |
$2,631.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,514.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,549.72
|
| Rate for Payer: Cash Price |
$877.20
|
| Rate for Payer: Cigna Commercial |
$2,690.08
|
| Rate for Payer: Health EOS Commercial |
$2,602.36
|
| Rate for Payer: HFN Commercial |
$2,690.08
|
| Rate for Payer: Multiplan Commercial |
$2,339.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,754.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,690.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,432.76
|
| Rate for Payer: Quartz Commercial |
$1,754.40
|
| Rate for Payer: WEA Trust Commercial |
$1,608.20
|
| Rate for Payer: WPS Commercial |
$2,165.81
|
|
|
PLATE 5 HL DISTAL FEMUR RT
|
Facility
|
OP
|
$2,924.00
|
|
| Hospital Charge Code |
2966349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$818.72 |
| Max. Negotiated Rate |
$11,696.00 |
| Rate for Payer: Aetna Commercial |
$2,631.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,514.64
|
| Rate for Payer: Aetna Managed Medicare |
$818.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,900.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,462.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,403.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,549.72
|
| Rate for Payer: Cash Price |
$877.20
|
| Rate for Payer: Cigna Commercial |
$2,690.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,636.27
|
| Rate for Payer: Health EOS Commercial |
$2,602.36
|
| Rate for Payer: HFN Commercial |
$2,690.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,193.00
|
| Rate for Payer: Multiplan Commercial |
$2,339.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,754.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,690.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,432.76
|
| Rate for Payer: Quartz Commercial |
$1,900.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,754.40
|
| Rate for Payer: The Alliance Commercial |
$11,696.00
|
| Rate for Payer: WEA Trust Commercial |
$1,608.20
|
| Rate for Payer: WPS Commercial |
$2,165.81
|
|
|
PLATE 5 HL LT MEDIAL DISTAL
|
Facility
|
OP
|
$6,869.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966350
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,923.32 |
| Max. Negotiated Rate |
$27,476.00 |
| Rate for Payer: Aetna Commercial |
$6,182.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,907.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,923.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,464.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,434.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,297.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,640.57
|
| Rate for Payer: Cash Price |
$2,060.70
|
| Rate for Payer: Cigna Commercial |
$6,319.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,843.89
|
| Rate for Payer: Health EOS Commercial |
$6,113.41
|
| Rate for Payer: HFN Commercial |
$6,319.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,151.75
|
| Rate for Payer: Multiplan Commercial |
$5,495.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,121.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,319.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,365.81
|
| Rate for Payer: Quartz Commercial |
$4,464.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,121.40
|
| Rate for Payer: The Alliance Commercial |
$27,476.00
|
| Rate for Payer: WEA Trust Commercial |
$3,777.95
|
| Rate for Payer: WPS Commercial |
$5,087.87
|
|
