|
PLATE 9H/4H LT DISTAL RADIUS 04.110.341
|
Facility
|
IP
|
$7,985.00
|
|
| Hospital Charge Code |
2966790
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.65 |
| Max. Negotiated Rate |
$7,346.20 |
| Rate for Payer: Aetna Commercial |
$7,186.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,867.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,232.05
|
| Rate for Payer: Cash Price |
$2,395.50
|
| Rate for Payer: Cigna Commercial |
$7,346.20
|
| Rate for Payer: Health EOS Commercial |
$7,106.65
|
| Rate for Payer: HFN Commercial |
$7,346.20
|
| Rate for Payer: Multiplan Commercial |
$6,388.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,791.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,346.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,912.65
|
| Rate for Payer: Quartz Commercial |
$4,791.00
|
| Rate for Payer: WEA Trust Commercial |
$4,391.75
|
| Rate for Payer: WPS Commercial |
$5,914.49
|
|
|
PLATE 9H/4H LT DISTAL RADIUS 04.110.341
|
Facility
|
OP
|
$7,985.00
|
|
| Hospital Charge Code |
2966790
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,235.80 |
| Max. Negotiated Rate |
$31,940.00 |
| Rate for Payer: Aetna Commercial |
$7,186.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,867.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,235.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,190.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,992.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,832.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,232.05
|
| Rate for Payer: Cash Price |
$2,395.50
|
| Rate for Payer: Cigna Commercial |
$7,346.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,468.41
|
| Rate for Payer: Health EOS Commercial |
$7,106.65
|
| Rate for Payer: HFN Commercial |
$7,346.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,988.75
|
| Rate for Payer: Multiplan Commercial |
$6,388.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,791.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,346.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,912.65
|
| Rate for Payer: Quartz Commercial |
$5,190.25
|
| Rate for Payer: Quartz Medicare Advantage |
$4,791.00
|
| Rate for Payer: The Alliance Commercial |
$31,940.00
|
| Rate for Payer: WEA Trust Commercial |
$4,391.75
|
| Rate for Payer: WPS Commercial |
$5,914.49
|
|
|
PLATE 9H/4H RT DISTAL RADIUS 04.110.340
|
Facility
|
IP
|
$7,985.00
|
|
| Hospital Charge Code |
2966791
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.65 |
| Max. Negotiated Rate |
$7,346.20 |
| Rate for Payer: Aetna Commercial |
$7,186.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,867.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,232.05
|
| Rate for Payer: Cash Price |
$2,395.50
|
| Rate for Payer: Cigna Commercial |
$7,346.20
|
| Rate for Payer: Health EOS Commercial |
$7,106.65
|
| Rate for Payer: HFN Commercial |
$7,346.20
|
| Rate for Payer: Multiplan Commercial |
$6,388.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,791.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,346.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,912.65
|
| Rate for Payer: Quartz Commercial |
$4,791.00
|
| Rate for Payer: WEA Trust Commercial |
$4,391.75
|
| Rate for Payer: WPS Commercial |
$5,914.49
|
|
|
PLATE 9H/4H RT DISTAL RADIUS 04.110.340
|
Facility
|
OP
|
$7,985.00
|
|
| Hospital Charge Code |
2966791
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,235.80 |
| Max. Negotiated Rate |
$31,940.00 |
| Rate for Payer: Aetna Commercial |
$7,186.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,867.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,235.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,190.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,992.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,832.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,232.05
|
| Rate for Payer: Cash Price |
$2,395.50
|
| Rate for Payer: Cigna Commercial |
$7,346.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,468.41
|
| Rate for Payer: Health EOS Commercial |
$7,106.65
|
| Rate for Payer: HFN Commercial |
$7,346.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,988.75
|
| Rate for Payer: Multiplan Commercial |
$6,388.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,791.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,346.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,912.65
|
| Rate for Payer: Quartz Commercial |
$5,190.25
|
| Rate for Payer: Quartz Medicare Advantage |
$4,791.00
|
| Rate for Payer: The Alliance Commercial |
$31,940.00
|
| Rate for Payer: WEA Trust Commercial |
$4,391.75
|
| Rate for Payer: WPS Commercial |
$5,914.49
|
|
|
PLATE 9H/5H LT DISTAL RADIUS 04.110.351
|
Facility
|
IP
|
$7,985.00
|
|
| Hospital Charge Code |
2966792
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.65 |
| Max. Negotiated Rate |
$7,346.20 |
| Rate for Payer: Aetna Commercial |
$7,186.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,867.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,232.05
|
| Rate for Payer: Cash Price |
$2,395.50
|
| Rate for Payer: Cigna Commercial |
$7,346.20
|
| Rate for Payer: Health EOS Commercial |
$7,106.65
|
| Rate for Payer: HFN Commercial |
$7,346.20
|
| Rate for Payer: Multiplan Commercial |
$6,388.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,791.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,346.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,912.65
|
| Rate for Payer: Quartz Commercial |
$4,791.00
|
| Rate for Payer: WEA Trust Commercial |
$4,391.75
|
| Rate for Payer: WPS Commercial |
$5,914.49
|
|
|
PLATE 9H/5H LT DISTAL RADIUS 04.110.351
|
Facility
|
OP
|
$7,985.00
|
|
| Hospital Charge Code |
2966792
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,235.80 |
| Max. Negotiated Rate |
$31,940.00 |
| Rate for Payer: Aetna Commercial |
$7,186.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,867.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,235.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,190.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,992.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,832.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,232.05
|
| Rate for Payer: Cash Price |
$2,395.50
|
| Rate for Payer: Cigna Commercial |
$7,346.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,468.41
|
| Rate for Payer: Health EOS Commercial |
$7,106.65
|
| Rate for Payer: HFN Commercial |
$7,346.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,988.75
|
| Rate for Payer: Multiplan Commercial |
$6,388.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,791.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,346.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,912.65
|
| Rate for Payer: Quartz Commercial |
$5,190.25
|
| Rate for Payer: Quartz Medicare Advantage |
$4,791.00
|
| Rate for Payer: The Alliance Commercial |
$31,940.00
|
| Rate for Payer: WEA Trust Commercial |
$4,391.75
|
| Rate for Payer: WPS Commercial |
$5,914.49
|
|
|
PLATE 9H/5H RT DISTAL RADIUS 04.110.350
|
Facility
|
IP
|
$7,985.00
|
|
| Hospital Charge Code |
2966793
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.65 |
| Max. Negotiated Rate |
$7,346.20 |
| Rate for Payer: Aetna Commercial |
$7,186.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,867.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,232.05
|
| Rate for Payer: Cash Price |
$2,395.50
|
| Rate for Payer: Cigna Commercial |
$7,346.20
|
| Rate for Payer: Health EOS Commercial |
$7,106.65
|
| Rate for Payer: HFN Commercial |
$7,346.20
|
| Rate for Payer: Multiplan Commercial |
$6,388.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,791.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,346.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,912.65
|
| Rate for Payer: Quartz Commercial |
$4,791.00
|
| Rate for Payer: WEA Trust Commercial |
$4,391.75
|
| Rate for Payer: WPS Commercial |
$5,914.49
|
|
|
PLATE 9H/5H RT DISTAL RADIUS 04.110.350
|
Facility
|
OP
|
$7,985.00
|
|
| Hospital Charge Code |
2966793
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,235.80 |
| Max. Negotiated Rate |
$31,940.00 |
| Rate for Payer: Aetna Commercial |
$7,186.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,867.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,235.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,190.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,992.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,832.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,232.05
|
| Rate for Payer: Cash Price |
$2,395.50
|
| Rate for Payer: Cigna Commercial |
$7,346.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,468.41
|
| Rate for Payer: Health EOS Commercial |
$7,106.65
|
| Rate for Payer: HFN Commercial |
$7,346.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,988.75
|
| Rate for Payer: Multiplan Commercial |
$6,388.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,791.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,346.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,912.65
|
| Rate for Payer: Quartz Commercial |
$5,190.25
|
| Rate for Payer: Quartz Medicare Advantage |
$4,791.00
|
| Rate for Payer: The Alliance Commercial |
$31,940.00
|
| Rate for Payer: WEA Trust Commercial |
$4,391.75
|
| Rate for Payer: WPS Commercial |
$5,914.49
|
|
|
PLATE ACULOC 2 STD LT 70-0356
|
Facility
|
OP
|
$7,503.00
|
|
| Hospital Charge Code |
2967388
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,100.84 |
| Max. Negotiated Rate |
$30,012.00 |
| Rate for Payer: Aetna Commercial |
$6,752.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,452.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,100.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,876.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,751.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,601.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,976.59
|
| Rate for Payer: Cash Price |
$2,250.90
|
| Rate for Payer: Cigna Commercial |
$6,902.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,198.68
|
| Rate for Payer: Health EOS Commercial |
$6,677.67
|
| Rate for Payer: HFN Commercial |
$6,902.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,627.25
|
| Rate for Payer: Multiplan Commercial |
$6,002.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,501.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,902.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,676.47
|
| Rate for Payer: Quartz Commercial |
$4,876.95
|
| Rate for Payer: Quartz Medicare Advantage |
$4,501.80
|
| Rate for Payer: The Alliance Commercial |
$30,012.00
|
| Rate for Payer: WEA Trust Commercial |
$4,126.65
|
| Rate for Payer: WPS Commercial |
$5,557.47
|
|
|
PLATE ACULOC 2 STD LT 70-0356
|
Facility
|
IP
|
$7,503.00
|
|
| Hospital Charge Code |
2967388
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,676.47 |
| Max. Negotiated Rate |
$6,902.76 |
| Rate for Payer: Aetna Commercial |
$6,752.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,452.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,976.59
|
| Rate for Payer: Cash Price |
$2,250.90
|
| Rate for Payer: Cigna Commercial |
$6,902.76
|
| Rate for Payer: Health EOS Commercial |
$6,677.67
|
| Rate for Payer: HFN Commercial |
$6,902.76
|
| Rate for Payer: Multiplan Commercial |
$6,002.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,501.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,902.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,676.47
|
| Rate for Payer: Quartz Commercial |
$4,501.80
|
| Rate for Payer: WEA Trust Commercial |
$4,126.65
|
| Rate for Payer: WPS Commercial |
$5,557.47
|
|
|
PLATE ACULOC 2 VDR EXTENTION NEUTRAL 70-0364
|
Facility
|
OP
|
$6,790.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,901.20 |
| Max. Negotiated Rate |
$27,160.00 |
| Rate for Payer: Aetna Commercial |
$6,111.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,839.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,901.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,413.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,395.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,259.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,598.70
|
| Rate for Payer: Cash Price |
$2,037.00
|
| Rate for Payer: Cigna Commercial |
$6,246.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,799.68
|
| Rate for Payer: Health EOS Commercial |
$6,043.10
|
| Rate for Payer: HFN Commercial |
$6,246.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,092.50
|
| Rate for Payer: Multiplan Commercial |
$5,432.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,074.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,246.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,327.10
|
| Rate for Payer: Quartz Commercial |
$4,413.50
|
| Rate for Payer: Quartz Medicare Advantage |
$4,074.00
|
| Rate for Payer: The Alliance Commercial |
$27,160.00
|
| Rate for Payer: WEA Trust Commercial |
$3,734.50
|
| Rate for Payer: WPS Commercial |
$5,029.35
|
|
|
PLATE ACULOC 2 VDR EXTENTION NEUTRAL 70-0364
|
Facility
|
IP
|
$6,790.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,327.10 |
| Max. Negotiated Rate |
$6,246.80 |
| Rate for Payer: Aetna Commercial |
$6,111.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,839.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,598.70
|
| Rate for Payer: Cash Price |
$2,037.00
|
| Rate for Payer: Cigna Commercial |
$6,246.80
|
| Rate for Payer: Health EOS Commercial |
$6,043.10
|
| Rate for Payer: HFN Commercial |
$6,246.80
|
| Rate for Payer: Multiplan Commercial |
$5,432.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,074.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,246.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,327.10
|
| Rate for Payer: Quartz Commercial |
$4,074.00
|
| Rate for Payer: WEA Trust Commercial |
$3,734.50
|
| Rate for Payer: WPS Commercial |
$5,029.35
|
|
|
PLATE ACU-LOC 2 VDR NARROW LONG LT 70-0370
|
Facility
|
IP
|
$8,524.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5385155
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,176.76 |
| Max. Negotiated Rate |
$7,842.08 |
| Rate for Payer: Aetna Commercial |
$7,671.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,330.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,517.72
|
| Rate for Payer: Cash Price |
$2,557.20
|
| Rate for Payer: Cigna Commercial |
$7,842.08
|
| Rate for Payer: Health EOS Commercial |
$7,586.36
|
| Rate for Payer: HFN Commercial |
$7,842.08
|
| Rate for Payer: Multiplan Commercial |
$6,819.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,114.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,842.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,176.76
|
| Rate for Payer: Quartz Commercial |
$5,114.40
|
| Rate for Payer: WEA Trust Commercial |
$4,688.20
|
| Rate for Payer: WPS Commercial |
$6,313.73
|
|
|
PLATE ACU-LOC 2 VDR NARROW LONG LT 70-0370
|
Facility
|
OP
|
$8,524.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5385155
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,386.72 |
| Max. Negotiated Rate |
$34,096.00 |
| Rate for Payer: Aetna Commercial |
$7,671.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,330.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,386.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,540.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,091.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,517.72
|
| Rate for Payer: Cash Price |
$2,557.20
|
| Rate for Payer: Cigna Commercial |
$7,842.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,770.03
|
| Rate for Payer: Health EOS Commercial |
$7,586.36
|
| Rate for Payer: HFN Commercial |
$7,842.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,393.00
|
| Rate for Payer: Multiplan Commercial |
$6,819.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,114.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,842.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,176.76
|
| Rate for Payer: Quartz Commercial |
$5,540.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,114.40
|
| Rate for Payer: The Alliance Commercial |
$34,096.00
|
| Rate for Payer: WEA Trust Commercial |
$4,688.20
|
| Rate for Payer: WPS Commercial |
$6,313.73
|
|
|
PLATE ACU-LOC 2 VDR NARROW LT 70-0358
|
Facility
|
IP
|
$8,524.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,176.76 |
| Max. Negotiated Rate |
$7,842.08 |
| Rate for Payer: Aetna Commercial |
$7,671.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,330.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,517.72
|
| Rate for Payer: Cash Price |
$2,557.20
|
| Rate for Payer: Cigna Commercial |
$7,842.08
|
| Rate for Payer: Health EOS Commercial |
$7,586.36
|
| Rate for Payer: HFN Commercial |
$7,842.08
|
| Rate for Payer: Multiplan Commercial |
$6,819.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,114.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,842.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,176.76
|
| Rate for Payer: Quartz Commercial |
$5,114.40
|
| Rate for Payer: WEA Trust Commercial |
$4,688.20
|
| Rate for Payer: WPS Commercial |
$6,313.73
|
|
|
PLATE ACU-LOC 2 VDR NARROW LT 70-0358
|
Facility
|
OP
|
$8,524.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,386.72 |
| Max. Negotiated Rate |
$34,096.00 |
| Rate for Payer: Aetna Commercial |
$7,671.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,330.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,386.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,540.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,091.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,517.72
|
| Rate for Payer: Cash Price |
$2,557.20
|
| Rate for Payer: Cigna Commercial |
$7,842.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,770.03
|
| Rate for Payer: Health EOS Commercial |
$7,586.36
|
| Rate for Payer: HFN Commercial |
$7,842.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,393.00
|
| Rate for Payer: Multiplan Commercial |
$6,819.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,114.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,842.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,176.76
|
| Rate for Payer: Quartz Commercial |
$5,540.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,114.40
|
| Rate for Payer: The Alliance Commercial |
$34,096.00
|
| Rate for Payer: WEA Trust Commercial |
$4,688.20
|
| Rate for Payer: WPS Commercial |
$6,313.73
|
|
|
PLATE ACU-LOC 2 VDR NARROW RT 70-0359
|
Facility
|
OP
|
$8,852.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,478.56 |
| Max. Negotiated Rate |
$35,408.00 |
| Rate for Payer: Aetna Commercial |
$7,966.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,612.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,478.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,753.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,426.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,248.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.56
|
| Rate for Payer: Cash Price |
$2,655.60
|
| Rate for Payer: Cigna Commercial |
$8,143.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,953.58
|
| Rate for Payer: Health EOS Commercial |
$7,878.28
|
| Rate for Payer: HFN Commercial |
$8,143.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,639.00
|
| Rate for Payer: Multiplan Commercial |
$7,081.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,311.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,143.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,337.48
|
| Rate for Payer: Quartz Commercial |
$5,753.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,311.20
|
| Rate for Payer: The Alliance Commercial |
$35,408.00
|
| Rate for Payer: WEA Trust Commercial |
$4,868.60
|
| Rate for Payer: WPS Commercial |
$6,556.68
|
|
|
PLATE ACU-LOC 2 VDR NARROW RT 70-0359
|
Facility
|
IP
|
$8,852.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,337.48 |
| Max. Negotiated Rate |
$8,143.84 |
| Rate for Payer: Aetna Commercial |
$7,966.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,612.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.56
|
| Rate for Payer: Cash Price |
$2,655.60
|
| Rate for Payer: Cigna Commercial |
$8,143.84
|
| Rate for Payer: Health EOS Commercial |
$7,878.28
|
| Rate for Payer: HFN Commercial |
$8,143.84
|
| Rate for Payer: Multiplan Commercial |
$7,081.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,311.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,143.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,337.48
|
| Rate for Payer: Quartz Commercial |
$5,311.20
|
| Rate for Payer: WEA Trust Commercial |
$4,868.60
|
| Rate for Payer: WPS Commercial |
$6,556.68
|
|
|
PLATE ACU-LOC 2 VDR PROXIMAL STD LT 70-0350
|
Facility
|
OP
|
$11,493.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175440
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,218.04 |
| Max. Negotiated Rate |
$45,972.00 |
| Rate for Payer: Aetna Commercial |
$10,343.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,883.98
|
| Rate for Payer: Aetna Managed Medicare |
$3,218.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,470.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,746.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,516.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,091.29
|
| Rate for Payer: Cash Price |
$3,447.90
|
| Rate for Payer: Cigna Commercial |
$10,573.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,431.48
|
| Rate for Payer: Health EOS Commercial |
$10,228.77
|
| Rate for Payer: HFN Commercial |
$10,573.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,619.75
|
| Rate for Payer: Multiplan Commercial |
$9,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,895.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,573.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,631.57
|
| Rate for Payer: Quartz Commercial |
$7,470.45
|
| Rate for Payer: Quartz Medicare Advantage |
$6,895.80
|
| Rate for Payer: The Alliance Commercial |
$45,972.00
|
| Rate for Payer: WEA Trust Commercial |
$6,321.15
|
| Rate for Payer: WPS Commercial |
$8,512.87
|
|
|
PLATE ACU-LOC 2 VDR PROXIMAL STD LT 70-0350
|
Facility
|
IP
|
$11,493.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175440
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,631.57 |
| Max. Negotiated Rate |
$10,573.56 |
| Rate for Payer: Aetna Commercial |
$10,343.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,883.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,091.29
|
| Rate for Payer: Cash Price |
$3,447.90
|
| Rate for Payer: Cigna Commercial |
$10,573.56
|
| Rate for Payer: Health EOS Commercial |
$10,228.77
|
| Rate for Payer: HFN Commercial |
$10,573.56
|
| Rate for Payer: Multiplan Commercial |
$9,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,895.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,573.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,631.57
|
| Rate for Payer: Quartz Commercial |
$6,895.80
|
| Rate for Payer: WEA Trust Commercial |
$6,321.15
|
| Rate for Payer: WPS Commercial |
$8,512.87
|
|
|
PLATE ACU-LOC 2 VDR PROXIMAL STD RT 70-0351
|
Facility
|
IP
|
$8,823.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,323.27 |
| Max. Negotiated Rate |
$8,117.16 |
| Rate for Payer: Aetna Commercial |
$7,940.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,587.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,676.19
|
| Rate for Payer: Cash Price |
$2,646.90
|
| Rate for Payer: Cigna Commercial |
$8,117.16
|
| Rate for Payer: Health EOS Commercial |
$7,852.47
|
| Rate for Payer: HFN Commercial |
$8,117.16
|
| Rate for Payer: Multiplan Commercial |
$7,058.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,293.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,117.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,323.27
|
| Rate for Payer: Quartz Commercial |
$5,293.80
|
| Rate for Payer: WEA Trust Commercial |
$4,852.65
|
| Rate for Payer: WPS Commercial |
$6,535.20
|
|
|
PLATE ACU-LOC 2 VDR PROXIMAL STD RT 70-0351
|
Facility
|
OP
|
$8,823.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.44 |
| Max. Negotiated Rate |
$35,292.00 |
| Rate for Payer: Aetna Commercial |
$7,940.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,587.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,470.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,734.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,411.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,235.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,676.19
|
| Rate for Payer: Cash Price |
$2,646.90
|
| Rate for Payer: Cigna Commercial |
$8,117.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,937.35
|
| Rate for Payer: Health EOS Commercial |
$7,852.47
|
| Rate for Payer: HFN Commercial |
$8,117.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,617.25
|
| Rate for Payer: Multiplan Commercial |
$7,058.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,293.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,117.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,323.27
|
| Rate for Payer: Quartz Commercial |
$5,734.95
|
| Rate for Payer: Quartz Medicare Advantage |
$5,293.80
|
| Rate for Payer: The Alliance Commercial |
$35,292.00
|
| Rate for Payer: WEA Trust Commercial |
$4,852.65
|
| Rate for Payer: WPS Commercial |
$6,535.20
|
|
|
PLATE ACU-LOC 2 VDR PROXIMAL WIDE RT 70-0355
|
Facility
|
OP
|
$11,051.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6192975
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,094.28 |
| Max. Negotiated Rate |
$44,204.00 |
| Rate for Payer: Aetna Commercial |
$9,945.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,503.86
|
| Rate for Payer: Aetna Managed Medicare |
$3,094.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,183.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,525.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,304.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,857.03
|
| Rate for Payer: Cash Price |
$3,315.30
|
| Rate for Payer: Cigna Commercial |
$10,166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,184.14
|
| Rate for Payer: Health EOS Commercial |
$9,835.39
|
| Rate for Payer: HFN Commercial |
$10,166.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,288.25
|
| Rate for Payer: Multiplan Commercial |
$8,840.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,630.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,166.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,414.99
|
| Rate for Payer: Quartz Commercial |
$7,183.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,630.60
|
| Rate for Payer: The Alliance Commercial |
$44,204.00
|
| Rate for Payer: WEA Trust Commercial |
$6,078.05
|
| Rate for Payer: WPS Commercial |
$8,185.48
|
|
|
PLATE ACU-LOC 2 VDR PROXIMAL WIDE RT 70-0355
|
Facility
|
IP
|
$11,051.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6192975
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,414.99 |
| Max. Negotiated Rate |
$10,166.92 |
| Rate for Payer: Aetna Commercial |
$9,945.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,503.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,857.03
|
| Rate for Payer: Cash Price |
$3,315.30
|
| Rate for Payer: Cigna Commercial |
$10,166.92
|
| Rate for Payer: Health EOS Commercial |
$9,835.39
|
| Rate for Payer: HFN Commercial |
$10,166.92
|
| Rate for Payer: Multiplan Commercial |
$8,840.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,630.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,166.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,414.99
|
| Rate for Payer: Quartz Commercial |
$6,630.60
|
| Rate for Payer: WEA Trust Commercial |
$6,078.05
|
| Rate for Payer: WPS Commercial |
$8,185.48
|
|
|
PLATE ACU-LOC 2 VDR PROX STD LONG RT 70-0373
|
Facility
|
IP
|
$11,051.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6181295
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,414.99 |
| Max. Negotiated Rate |
$10,166.92 |
| Rate for Payer: Aetna Commercial |
$9,945.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,503.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,857.03
|
| Rate for Payer: Cash Price |
$3,315.30
|
| Rate for Payer: Cigna Commercial |
$10,166.92
|
| Rate for Payer: Health EOS Commercial |
$9,835.39
|
| Rate for Payer: HFN Commercial |
$10,166.92
|
| Rate for Payer: Multiplan Commercial |
$8,840.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,630.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,166.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,414.99
|
| Rate for Payer: Quartz Commercial |
$6,630.60
|
| Rate for Payer: WEA Trust Commercial |
$6,078.05
|
| Rate for Payer: WPS Commercial |
$8,185.48
|
|
