|
PLATE ACU-LOC 2 VDR PROX STD LONG RT 70-0373
|
Facility
|
OP
|
$11,051.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6181295
|
|
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 STD RT 70-0357
|
Facility
|
IP
|
$8,852.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5248649
|
|
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 STD RT 70-0357
|
Facility
|
OP
|
$8,852.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5248649
|
|
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 WIDE RT 70-0361
|
Facility
|
IP
|
$8,524.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4998623
|
|
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 WIDE RT 70-0361
|
Facility
|
OP
|
$8,524.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4998623
|
|
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 VDR STD. RIGHT
|
Facility
|
IP
|
$7,093.00
|
|
| Hospital Charge Code |
2964146
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,475.57 |
| Max. Negotiated Rate |
$6,525.56 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,255.80
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
PLATE ACU-LOC VDR STD. RIGHT
|
Facility
|
OP
|
$7,093.00
|
|
| Hospital Charge Code |
2964146
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,986.04 |
| Max. Negotiated Rate |
$28,372.00 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,986.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,610.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,546.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,404.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,969.24
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,319.75
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,610.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,255.80
|
| Rate for Payer: The Alliance Commercial |
$28,372.00
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
PLATE ACUTIE STERNUM WIRE STW-1104
|
Facility
|
OP
|
$4,593.00
|
|
| Hospital Charge Code |
2964166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,286.04 |
| Max. Negotiated Rate |
$18,372.00 |
| Rate for Payer: Aetna Commercial |
$4,133.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,949.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,286.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,985.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,296.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,204.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,434.29
|
| Rate for Payer: Cash Price |
$1,377.90
|
| Rate for Payer: Cigna Commercial |
$4,225.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,570.24
|
| Rate for Payer: Health EOS Commercial |
$4,087.77
|
| Rate for Payer: HFN Commercial |
$4,225.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,444.75
|
| Rate for Payer: Multiplan Commercial |
$3,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,755.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,225.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,250.57
|
| Rate for Payer: Quartz Commercial |
$2,985.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,755.80
|
| Rate for Payer: The Alliance Commercial |
$18,372.00
|
| Rate for Payer: WEA Trust Commercial |
$2,526.15
|
| Rate for Payer: WPS Commercial |
$3,402.04
|
|
|
PLATE ACUTIE STERNUM WIRE STW-1104
|
Facility
|
IP
|
$4,593.00
|
|
| Hospital Charge Code |
2964166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,250.57 |
| Max. Negotiated Rate |
$4,225.56 |
| Rate for Payer: Aetna Commercial |
$4,133.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,949.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,434.29
|
| Rate for Payer: Cash Price |
$1,377.90
|
| Rate for Payer: Cigna Commercial |
$4,225.56
|
| Rate for Payer: Health EOS Commercial |
$4,087.77
|
| Rate for Payer: HFN Commercial |
$4,225.56
|
| Rate for Payer: Multiplan Commercial |
$3,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,755.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,225.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,250.57
|
| Rate for Payer: Quartz Commercial |
$2,755.80
|
| Rate for Payer: WEA Trust Commercial |
$2,526.15
|
| Rate for Payer: WPS Commercial |
$3,402.04
|
|
|
PLATE AMBI 120DEG 4HL 91-5968
|
Facility
|
OP
|
$5,753.00
|
|
| Hospital Charge Code |
2966015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.84 |
| Max. Negotiated Rate |
$23,012.00 |
| Rate for Payer: Aetna Commercial |
$5,177.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,947.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,610.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,739.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,876.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,761.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.09
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$5,292.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,219.38
|
| Rate for Payer: Health EOS Commercial |
$5,120.17
|
| Rate for Payer: HFN Commercial |
$5,292.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,314.75
|
| Rate for Payer: Multiplan Commercial |
$4,602.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,292.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,818.97
|
| Rate for Payer: Quartz Commercial |
$3,739.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,451.80
|
| Rate for Payer: The Alliance Commercial |
$23,012.00
|
| Rate for Payer: WEA Trust Commercial |
$3,164.15
|
| Rate for Payer: WPS Commercial |
$4,261.25
|
|
|
PLATE AMBI 120DEG 4HL 91-5968
|
Facility
|
IP
|
$5,753.00
|
|
| Hospital Charge Code |
2966015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,818.97 |
| Max. Negotiated Rate |
$5,292.76 |
| Rate for Payer: Aetna Commercial |
$5,177.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,947.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.09
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$5,292.76
|
| Rate for Payer: Health EOS Commercial |
$5,120.17
|
| Rate for Payer: HFN Commercial |
$5,292.76
|
| Rate for Payer: Multiplan Commercial |
$4,602.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,292.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,818.97
|
| Rate for Payer: Quartz Commercial |
$3,451.80
|
| Rate for Payer: WEA Trust Commercial |
$3,164.15
|
| Rate for Payer: WPS Commercial |
$4,261.25
|
|
|
PLATE AMBI 125DEG 4HL 91-4543
|
Facility
|
IP
|
$5,753.00
|
|
| Hospital Charge Code |
2966016
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,818.97 |
| Max. Negotiated Rate |
$5,292.76 |
| Rate for Payer: Aetna Commercial |
$5,177.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,947.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.09
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$5,292.76
|
| Rate for Payer: Health EOS Commercial |
$5,120.17
|
| Rate for Payer: HFN Commercial |
$5,292.76
|
| Rate for Payer: Multiplan Commercial |
$4,602.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,292.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,818.97
|
| Rate for Payer: Quartz Commercial |
$3,451.80
|
| Rate for Payer: WEA Trust Commercial |
$3,164.15
|
| Rate for Payer: WPS Commercial |
$4,261.25
|
|
|
PLATE AMBI 125DEG 4HL 91-4543
|
Facility
|
OP
|
$5,753.00
|
|
| Hospital Charge Code |
2966016
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.84 |
| Max. Negotiated Rate |
$23,012.00 |
| Rate for Payer: Aetna Commercial |
$5,177.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,947.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,610.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,739.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,876.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,761.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.09
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$5,292.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,219.38
|
| Rate for Payer: Health EOS Commercial |
$5,120.17
|
| Rate for Payer: HFN Commercial |
$5,292.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,314.75
|
| Rate for Payer: Multiplan Commercial |
$4,602.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,292.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,818.97
|
| Rate for Payer: Quartz Commercial |
$3,739.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,451.80
|
| Rate for Payer: The Alliance Commercial |
$23,012.00
|
| Rate for Payer: WEA Trust Commercial |
$3,164.15
|
| Rate for Payer: WPS Commercial |
$4,261.25
|
|
|
PLATE AMBI 130DEG 3HL 124125
|
Facility
|
OP
|
$3,707.00
|
|
| Hospital Charge Code |
2966017
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.96 |
| Max. Negotiated Rate |
$14,828.00 |
| Rate for Payer: Aetna Commercial |
$3,336.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,188.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,037.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,409.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,853.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,779.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,964.71
|
| Rate for Payer: Cash Price |
$1,112.10
|
| Rate for Payer: Cigna Commercial |
$3,410.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,074.44
|
| Rate for Payer: Health EOS Commercial |
$3,299.23
|
| Rate for Payer: HFN Commercial |
$3,410.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,780.25
|
| Rate for Payer: Multiplan Commercial |
$2,965.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,224.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,410.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.43
|
| Rate for Payer: Quartz Commercial |
$2,409.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,224.20
|
| Rate for Payer: The Alliance Commercial |
$14,828.00
|
| Rate for Payer: WEA Trust Commercial |
$2,038.85
|
| Rate for Payer: WPS Commercial |
$2,745.77
|
|
|
PLATE AMBI 130DEG 3HL 124125
|
Facility
|
IP
|
$3,707.00
|
|
| Hospital Charge Code |
2966017
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,816.43 |
| Max. Negotiated Rate |
$3,410.44 |
| Rate for Payer: Aetna Commercial |
$3,336.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,188.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,964.71
|
| Rate for Payer: Cash Price |
$1,112.10
|
| Rate for Payer: Cigna Commercial |
$3,410.44
|
| Rate for Payer: Health EOS Commercial |
$3,299.23
|
| Rate for Payer: HFN Commercial |
$3,410.44
|
| Rate for Payer: Multiplan Commercial |
$2,965.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,224.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,410.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.43
|
| Rate for Payer: Quartz Commercial |
$2,224.20
|
| Rate for Payer: WEA Trust Commercial |
$2,038.85
|
| Rate for Payer: WPS Commercial |
$2,745.77
|
|
|
PLATE AMBI 130DEG 4HL 124130
|
Facility
|
OP
|
$3,707.00
|
|
| Hospital Charge Code |
2966018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.96 |
| Max. Negotiated Rate |
$14,828.00 |
| Rate for Payer: Aetna Commercial |
$3,336.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,188.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,037.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,409.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,853.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,779.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,964.71
|
| Rate for Payer: Cash Price |
$1,112.10
|
| Rate for Payer: Cigna Commercial |
$3,410.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,074.44
|
| Rate for Payer: Health EOS Commercial |
$3,299.23
|
| Rate for Payer: HFN Commercial |
$3,410.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,780.25
|
| Rate for Payer: Multiplan Commercial |
$2,965.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,224.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,410.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.43
|
| Rate for Payer: Quartz Commercial |
$2,409.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,224.20
|
| Rate for Payer: The Alliance Commercial |
$14,828.00
|
| Rate for Payer: WEA Trust Commercial |
$2,038.85
|
| Rate for Payer: WPS Commercial |
$2,745.77
|
|
|
PLATE AMBI 130DEG 4HL 124130
|
Facility
|
IP
|
$3,707.00
|
|
| Hospital Charge Code |
2966018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,816.43 |
| Max. Negotiated Rate |
$3,410.44 |
| Rate for Payer: Aetna Commercial |
$3,336.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,188.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,964.71
|
| Rate for Payer: Cash Price |
$1,112.10
|
| Rate for Payer: Cigna Commercial |
$3,410.44
|
| Rate for Payer: Health EOS Commercial |
$3,299.23
|
| Rate for Payer: HFN Commercial |
$3,410.44
|
| Rate for Payer: Multiplan Commercial |
$2,965.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,224.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,410.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.43
|
| Rate for Payer: Quartz Commercial |
$2,224.20
|
| Rate for Payer: WEA Trust Commercial |
$2,038.85
|
| Rate for Payer: WPS Commercial |
$2,745.77
|
|
|
PLATE AMBI 130DEG 5HL 124135
|
Facility
|
IP
|
$4,064.00
|
|
| Hospital Charge Code |
2966019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,991.36 |
| Max. Negotiated Rate |
$3,738.88 |
| Rate for Payer: Aetna Commercial |
$3,657.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,495.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,153.92
|
| Rate for Payer: Cash Price |
$1,219.20
|
| Rate for Payer: Cigna Commercial |
$3,738.88
|
| Rate for Payer: Health EOS Commercial |
$3,616.96
|
| Rate for Payer: HFN Commercial |
$3,738.88
|
| Rate for Payer: Multiplan Commercial |
$3,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,438.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,738.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,991.36
|
| Rate for Payer: Quartz Commercial |
$2,438.40
|
| Rate for Payer: WEA Trust Commercial |
$2,235.20
|
| Rate for Payer: WPS Commercial |
$3,010.20
|
|
|
PLATE AMBI 130DEG 5HL 124135
|
Facility
|
OP
|
$4,064.00
|
|
| Hospital Charge Code |
2966019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,137.92 |
| Max. Negotiated Rate |
$16,256.00 |
| Rate for Payer: Aetna Commercial |
$3,657.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,495.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,137.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,641.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,032.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,950.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,153.92
|
| Rate for Payer: Cash Price |
$1,219.20
|
| Rate for Payer: Cigna Commercial |
$3,738.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,274.21
|
| Rate for Payer: Health EOS Commercial |
$3,616.96
|
| Rate for Payer: HFN Commercial |
$3,738.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,048.00
|
| Rate for Payer: Multiplan Commercial |
$3,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,438.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,738.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,991.36
|
| Rate for Payer: Quartz Commercial |
$2,641.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,438.40
|
| Rate for Payer: The Alliance Commercial |
$16,256.00
|
| Rate for Payer: WEA Trust Commercial |
$2,235.20
|
| Rate for Payer: WPS Commercial |
$3,010.20
|
|
|
PLATE AMBI 130DEG 6HL 124140
|
Facility
|
OP
|
$4,064.00
|
|
| Hospital Charge Code |
2966020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,137.92 |
| Max. Negotiated Rate |
$16,256.00 |
| Rate for Payer: Aetna Commercial |
$3,657.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,495.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,137.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,641.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,032.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,950.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,153.92
|
| Rate for Payer: Cash Price |
$1,219.20
|
| Rate for Payer: Cigna Commercial |
$3,738.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,274.21
|
| Rate for Payer: Health EOS Commercial |
$3,616.96
|
| Rate for Payer: HFN Commercial |
$3,738.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,048.00
|
| Rate for Payer: Multiplan Commercial |
$3,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,438.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,738.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,991.36
|
| Rate for Payer: Quartz Commercial |
$2,641.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,438.40
|
| Rate for Payer: The Alliance Commercial |
$16,256.00
|
| Rate for Payer: WEA Trust Commercial |
$2,235.20
|
| Rate for Payer: WPS Commercial |
$3,010.20
|
|
|
PLATE AMBI 130DEG 6HL 124140
|
Facility
|
IP
|
$4,064.00
|
|
| Hospital Charge Code |
2966020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,991.36 |
| Max. Negotiated Rate |
$3,738.88 |
| Rate for Payer: Aetna Commercial |
$3,657.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,495.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,153.92
|
| Rate for Payer: Cash Price |
$1,219.20
|
| Rate for Payer: Cigna Commercial |
$3,738.88
|
| Rate for Payer: Health EOS Commercial |
$3,616.96
|
| Rate for Payer: HFN Commercial |
$3,738.88
|
| Rate for Payer: Multiplan Commercial |
$3,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,438.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,738.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,991.36
|
| Rate for Payer: Quartz Commercial |
$2,438.40
|
| Rate for Payer: WEA Trust Commercial |
$2,235.20
|
| Rate for Payer: WPS Commercial |
$3,010.20
|
|
|
PLATE AMBI 130DEG 8HL 124145
|
Facility
|
IP
|
$3,747.00
|
|
| Hospital Charge Code |
2966030
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,836.03 |
| Max. Negotiated Rate |
$3,447.24 |
| Rate for Payer: Aetna Commercial |
$3,372.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,222.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,985.91
|
| Rate for Payer: Cash Price |
$1,124.10
|
| Rate for Payer: Cigna Commercial |
$3,447.24
|
| Rate for Payer: Health EOS Commercial |
$3,334.83
|
| Rate for Payer: HFN Commercial |
$3,447.24
|
| Rate for Payer: Multiplan Commercial |
$2,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,248.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,447.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,836.03
|
| Rate for Payer: Quartz Commercial |
$2,248.20
|
| Rate for Payer: WEA Trust Commercial |
$2,060.85
|
| Rate for Payer: WPS Commercial |
$2,775.40
|
|
|
PLATE AMBI 130DEG 8HL 124145
|
Facility
|
OP
|
$3,747.00
|
|
| Hospital Charge Code |
2966030
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,049.16 |
| Max. Negotiated Rate |
$14,988.00 |
| Rate for Payer: Aetna Commercial |
$3,372.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,222.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,049.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,435.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,873.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,798.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,985.91
|
| Rate for Payer: Cash Price |
$1,124.10
|
| Rate for Payer: Cigna Commercial |
$3,447.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,096.82
|
| Rate for Payer: Health EOS Commercial |
$3,334.83
|
| Rate for Payer: HFN Commercial |
$3,447.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,810.25
|
| Rate for Payer: Multiplan Commercial |
$2,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,248.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,447.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,836.03
|
| Rate for Payer: Quartz Commercial |
$2,435.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,248.20
|
| Rate for Payer: The Alliance Commercial |
$14,988.00
|
| Rate for Payer: WEA Trust Commercial |
$2,060.85
|
| Rate for Payer: WPS Commercial |
$2,775.40
|
|
|
PLATE AMBI 135DEG 10HL 124151
|
Facility
|
OP
|
$5,753.00
|
|
| Hospital Charge Code |
2966031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.84 |
| Max. Negotiated Rate |
$23,012.00 |
| Rate for Payer: Aetna Commercial |
$5,177.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,947.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,610.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,739.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,876.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,761.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.09
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$5,292.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,219.38
|
| Rate for Payer: Health EOS Commercial |
$5,120.17
|
| Rate for Payer: HFN Commercial |
$5,292.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,314.75
|
| Rate for Payer: Multiplan Commercial |
$4,602.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,292.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,818.97
|
| Rate for Payer: Quartz Commercial |
$3,739.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,451.80
|
| Rate for Payer: The Alliance Commercial |
$23,012.00
|
| Rate for Payer: WEA Trust Commercial |
$3,164.15
|
| Rate for Payer: WPS Commercial |
$4,261.25
|
|
|
PLATE AMBI 135DEG 10HL 124151
|
Facility
|
IP
|
$5,753.00
|
|
| Hospital Charge Code |
2966031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,818.97 |
| Max. Negotiated Rate |
$5,292.76 |
| Rate for Payer: Aetna Commercial |
$5,177.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,947.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.09
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$5,292.76
|
| Rate for Payer: Health EOS Commercial |
$5,120.17
|
| Rate for Payer: HFN Commercial |
$5,292.76
|
| Rate for Payer: Multiplan Commercial |
$4,602.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,292.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,818.97
|
| Rate for Payer: Quartz Commercial |
$3,451.80
|
| Rate for Payer: WEA Trust Commercial |
$3,164.15
|
| Rate for Payer: WPS Commercial |
$4,261.25
|
|
