|
PLATE MINI RT 242.34
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5599596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$234.93 |
| Max. Negotiated Rate |
$441.08 |
| Rate for Payer: Aetna Commercial |
$431.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.10
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$441.08
|
| Rate for Payer: Health EOS Commercial |
$426.70
|
| Rate for Payer: HFN Commercial |
$441.08
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: Preferred Network Access Commercial |
$441.08
|
| Rate for Payer: Quartz Beloit One Network |
$234.93
|
| Rate for Payer: Quartz Commercial |
$287.66
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: WPS Commercial |
$355.11
|
|
|
PLATE MTP LEFT ORTHOLOC 3Di CROSSCHECK 5820MPX1L
|
Facility
|
OP
|
$13,390.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6099635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,899.17 |
| Max. Negotiated Rate |
$12,811.55 |
| Rate for Payer: Aetna Commercial |
$12,533.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,976.02
|
| Rate for Payer: Aetna Managed Medicare |
$3,899.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,051.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,962.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,684.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,380.57
|
| Rate for Payer: Cash Price |
$4,017.00
|
| Rate for Payer: Cigna Commercial |
$12,811.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,792.98
|
| Rate for Payer: Health EOS Commercial |
$12,393.78
|
| Rate for Payer: HFN Commercial |
$12,811.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,444.20
|
| Rate for Payer: Multiplan Commercial |
$11,140.48
|
| Rate for Payer: NAPHCARE Commercial |
$8,355.36
|
| Rate for Payer: Preferred Network Access Commercial |
$12,811.55
|
| Rate for Payer: Quartz Beloit One Network |
$6,823.54
|
| Rate for Payer: Quartz Commercial |
$9,051.64
|
| Rate for Payer: Quartz Medicare Advantage |
$8,355.36
|
| Rate for Payer: The Alliance Commercial |
$6,962.80
|
| Rate for Payer: WEA Trust Commercial |
$7,659.08
|
| Rate for Payer: WPS Commercial |
$10,314.32
|
|
|
PLATE MTP LEFT ORTHOLOC 3Di CROSSCHECK 5820MPX1L
|
Facility
|
IP
|
$13,390.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6099635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,823.54 |
| Max. Negotiated Rate |
$12,811.55 |
| Rate for Payer: Aetna Commercial |
$12,533.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,976.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,380.57
|
| Rate for Payer: Cash Price |
$4,017.00
|
| Rate for Payer: Cigna Commercial |
$12,811.55
|
| Rate for Payer: Health EOS Commercial |
$12,393.78
|
| Rate for Payer: HFN Commercial |
$12,811.55
|
| Rate for Payer: Multiplan Commercial |
$11,140.48
|
| Rate for Payer: Preferred Network Access Commercial |
$12,811.55
|
| Rate for Payer: Quartz Beloit One Network |
$6,823.54
|
| Rate for Payer: Quartz Commercial |
$8,355.36
|
| Rate for Payer: WEA Trust Commercial |
$7,659.08
|
| Rate for Payer: WPS Commercial |
$10,314.32
|
|
|
PLATE MTP LO-PRO CONTOURED TI SHORT RT AR-8944CR-P
|
Facility
|
IP
|
$7,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,639.05 |
| Max. Negotiated Rate |
$6,832.51 |
| Rate for Payer: Aetna Commercial |
$6,683.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,386.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,936.12
|
| Rate for Payer: Cash Price |
$2,142.30
|
| Rate for Payer: Cigna Commercial |
$6,832.51
|
| Rate for Payer: Health EOS Commercial |
$6,609.71
|
| Rate for Payer: HFN Commercial |
$6,832.51
|
| Rate for Payer: Multiplan Commercial |
$5,941.31
|
| Rate for Payer: Preferred Network Access Commercial |
$6,832.51
|
| Rate for Payer: Quartz Beloit One Network |
$3,639.05
|
| Rate for Payer: Quartz Commercial |
$4,455.98
|
| Rate for Payer: WEA Trust Commercial |
$4,084.65
|
| Rate for Payer: WPS Commercial |
$5,500.71
|
|
|
PLATE MTP LO-PRO CONTOURED TI SHORT RT AR-8944CR-P
|
Facility
|
OP
|
$7,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,079.46 |
| Max. Negotiated Rate |
$6,832.51 |
| Rate for Payer: Aetna Commercial |
$6,683.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,386.91
|
| Rate for Payer: Aetna Managed Medicare |
$2,079.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,827.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,713.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,564.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,936.12
|
| Rate for Payer: Cash Price |
$2,142.30
|
| Rate for Payer: Cigna Commercial |
$6,832.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,156.06
|
| Rate for Payer: Health EOS Commercial |
$6,609.71
|
| Rate for Payer: HFN Commercial |
$6,832.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,569.98
|
| Rate for Payer: Multiplan Commercial |
$5,941.31
|
| Rate for Payer: NAPHCARE Commercial |
$4,455.98
|
| Rate for Payer: Preferred Network Access Commercial |
$6,832.51
|
| Rate for Payer: Quartz Beloit One Network |
$3,639.05
|
| Rate for Payer: Quartz Commercial |
$4,827.32
|
| Rate for Payer: Quartz Medicare Advantage |
$4,455.98
|
| Rate for Payer: The Alliance Commercial |
$3,713.32
|
| Rate for Payer: WEA Trust Commercial |
$4,084.65
|
| Rate for Payer: WPS Commercial |
$5,500.71
|
|
|
PLATE MTP LO-PRO CONTOURED TI STD LT AR-8944CL-S
|
Facility
|
OP
|
$7,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5603770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,079.46 |
| Max. Negotiated Rate |
$6,832.51 |
| Rate for Payer: Aetna Commercial |
$6,683.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,386.91
|
| Rate for Payer: Aetna Managed Medicare |
$2,079.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,827.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,713.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,564.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,936.12
|
| Rate for Payer: Cash Price |
$2,142.30
|
| Rate for Payer: Cigna Commercial |
$6,832.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,156.06
|
| Rate for Payer: Health EOS Commercial |
$6,609.71
|
| Rate for Payer: HFN Commercial |
$6,832.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,569.98
|
| Rate for Payer: Multiplan Commercial |
$5,941.31
|
| Rate for Payer: NAPHCARE Commercial |
$4,455.98
|
| Rate for Payer: Preferred Network Access Commercial |
$6,832.51
|
| Rate for Payer: Quartz Beloit One Network |
$3,639.05
|
| Rate for Payer: Quartz Commercial |
$4,827.32
|
| Rate for Payer: Quartz Medicare Advantage |
$4,455.98
|
| Rate for Payer: The Alliance Commercial |
$3,713.32
|
| Rate for Payer: WEA Trust Commercial |
$4,084.65
|
| Rate for Payer: WPS Commercial |
$5,500.71
|
|
|
PLATE MTP LO-PRO CONTOURED TI STD LT AR-8944CL-S
|
Facility
|
IP
|
$7,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5603770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,639.05 |
| Max. Negotiated Rate |
$6,832.51 |
| Rate for Payer: Aetna Commercial |
$6,683.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,386.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,936.12
|
| Rate for Payer: Cash Price |
$2,142.30
|
| Rate for Payer: Cigna Commercial |
$6,832.51
|
| Rate for Payer: Health EOS Commercial |
$6,609.71
|
| Rate for Payer: HFN Commercial |
$6,832.51
|
| Rate for Payer: Multiplan Commercial |
$5,941.31
|
| Rate for Payer: Preferred Network Access Commercial |
$6,832.51
|
| Rate for Payer: Quartz Beloit One Network |
$3,639.05
|
| Rate for Payer: Quartz Commercial |
$4,455.98
|
| Rate for Payer: WEA Trust Commercial |
$4,084.65
|
| Rate for Payer: WPS Commercial |
$5,500.71
|
|
|
PLATE MTP RIGHT ORTHOLOC 3Di CROSSCHECK 5820MPX1R
|
Facility
|
OP
|
$14,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458985
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,130.38 |
| Max. Negotiated Rate |
$13,571.25 |
| Rate for Payer: Aetna Commercial |
$13,276.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,686.17
|
| Rate for Payer: Aetna Managed Medicare |
$4,130.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,588.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,375.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,080.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,818.22
|
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Cigna Commercial |
$13,571.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,255.09
|
| Rate for Payer: Health EOS Commercial |
$13,128.71
|
| Rate for Payer: HFN Commercial |
$13,571.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,063.52
|
| Rate for Payer: Multiplan Commercial |
$11,801.09
|
| Rate for Payer: NAPHCARE Commercial |
$8,850.82
|
| Rate for Payer: Preferred Network Access Commercial |
$13,571.25
|
| Rate for Payer: Quartz Beloit One Network |
$7,228.17
|
| Rate for Payer: Quartz Commercial |
$9,588.38
|
| Rate for Payer: Quartz Medicare Advantage |
$8,850.82
|
| Rate for Payer: The Alliance Commercial |
$7,375.68
|
| Rate for Payer: WEA Trust Commercial |
$8,113.25
|
| Rate for Payer: WPS Commercial |
$10,925.94
|
|
|
PLATE MTP RIGHT ORTHOLOC 3Di CROSSCHECK 5820MPX1R
|
Facility
|
IP
|
$14,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458985
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,228.17 |
| Max. Negotiated Rate |
$13,571.25 |
| Rate for Payer: Aetna Commercial |
$13,276.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,686.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,818.22
|
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Cigna Commercial |
$13,571.25
|
| Rate for Payer: Health EOS Commercial |
$13,128.71
|
| Rate for Payer: HFN Commercial |
$13,571.25
|
| Rate for Payer: Multiplan Commercial |
$11,801.09
|
| Rate for Payer: Preferred Network Access Commercial |
$13,571.25
|
| Rate for Payer: Quartz Beloit One Network |
$7,228.17
|
| Rate for Payer: Quartz Commercial |
$8,850.82
|
| Rate for Payer: WEA Trust Commercial |
$8,113.25
|
| Rate for Payer: WPS Commercial |
$10,925.94
|
|
|
PLATE NARROW LCP 10HL 224.601
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 10HL 224.601
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 12HL 224.621
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 12HL 224.621
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 4HL 224.541
|
Facility
|
OP
|
$5,040.00
|
|
| Hospital Charge Code |
2966766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.65 |
| Max. Negotiated Rate |
$4,822.27 |
| Rate for Payer: Aetna Commercial |
$4,717.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,507.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,620.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,515.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.05
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna Commercial |
$4,822.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.28
|
| Rate for Payer: Health EOS Commercial |
$4,665.02
|
| Rate for Payer: HFN Commercial |
$4,822.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.20
|
| Rate for Payer: Multiplan Commercial |
$4,193.28
|
| Rate for Payer: NAPHCARE Commercial |
$3,144.96
|
| Rate for Payer: Preferred Network Access Commercial |
$4,822.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.38
|
| Rate for Payer: Quartz Commercial |
$3,407.04
|
| Rate for Payer: Quartz Medicare Advantage |
$3,144.96
|
| Rate for Payer: The Alliance Commercial |
$2,620.80
|
| Rate for Payer: WEA Trust Commercial |
$2,882.88
|
| Rate for Payer: WPS Commercial |
$3,882.31
|
|
|
PLATE NARROW LCP 4HL 224.541
|
Facility
|
IP
|
$5,040.00
|
|
| Hospital Charge Code |
2966766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.38 |
| Max. Negotiated Rate |
$4,822.27 |
| Rate for Payer: Aetna Commercial |
$4,717.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,507.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.05
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna Commercial |
$4,822.27
|
| Rate for Payer: Health EOS Commercial |
$4,665.02
|
| Rate for Payer: HFN Commercial |
$4,822.27
|
| Rate for Payer: Multiplan Commercial |
$4,193.28
|
| Rate for Payer: Preferred Network Access Commercial |
$4,822.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.38
|
| Rate for Payer: Quartz Commercial |
$3,144.96
|
| Rate for Payer: WEA Trust Commercial |
$2,882.88
|
| Rate for Payer: WPS Commercial |
$3,882.31
|
|
|
PLATE NARROW LCP 5HL 224.551
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 5HL 224.551
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 6HL 224.561
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 6HL 224.561
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 7HL 224.571
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 7HL 224.571
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 8HL 224.581
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 8HL 224.581
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 9HL 224.591
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 9HL 224.591
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
