|
PLATE SEMI TUBULAR 3HL 222.03
|
Facility
|
OP
|
$373.00
|
|
| Hospital Charge Code |
2966778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$108.62 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Aetna Managed Medicare |
$108.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$193.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.09
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$290.94
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: NAPHCARE Commercial |
$232.75
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$252.15
|
| Rate for Payer: Quartz Medicare Advantage |
$232.75
|
| Rate for Payer: The Alliance Commercial |
$193.96
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
PLATE SEMI TUBULAR 4HL 222.04
|
Facility
|
IP
|
$405.00
|
|
| Hospital Charge Code |
2966779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.39 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$252.72
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
PLATE SEMI TUBULAR 4HL 222.04
|
Facility
|
OP
|
$405.00
|
|
| Hospital Charge Code |
2966779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Aetna Managed Medicare |
$117.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$273.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$210.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$202.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.71
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.90
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: NAPHCARE Commercial |
$252.72
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$273.78
|
| Rate for Payer: Quartz Medicare Advantage |
$252.72
|
| Rate for Payer: The Alliance Commercial |
$210.60
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
PLATE SEMI TUBULAR 5HL 222.05
|
Facility
|
OP
|
$422.00
|
|
| Hospital Charge Code |
2966780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.89 |
| Max. Negotiated Rate |
$403.77 |
| Rate for Payer: Aetna Commercial |
$394.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$377.44
|
| Rate for Payer: Aetna Managed Medicare |
$122.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$285.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$219.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$210.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.61
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$403.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.60
|
| Rate for Payer: Health EOS Commercial |
$390.60
|
| Rate for Payer: HFN Commercial |
$403.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$329.16
|
| Rate for Payer: Multiplan Commercial |
$351.10
|
| Rate for Payer: NAPHCARE Commercial |
$263.33
|
| Rate for Payer: Preferred Network Access Commercial |
$403.77
|
| Rate for Payer: Quartz Beloit One Network |
$215.05
|
| Rate for Payer: Quartz Commercial |
$285.27
|
| Rate for Payer: Quartz Medicare Advantage |
$263.33
|
| Rate for Payer: The Alliance Commercial |
$219.44
|
| Rate for Payer: WEA Trust Commercial |
$241.38
|
| Rate for Payer: WPS Commercial |
$325.07
|
|
|
PLATE SEMI TUBULAR 5HL 222.05
|
Facility
|
IP
|
$422.00
|
|
| Hospital Charge Code |
2966780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$215.05 |
| Max. Negotiated Rate |
$403.77 |
| Rate for Payer: Aetna Commercial |
$394.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$377.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.61
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$403.77
|
| Rate for Payer: Health EOS Commercial |
$390.60
|
| Rate for Payer: HFN Commercial |
$403.77
|
| Rate for Payer: Multiplan Commercial |
$351.10
|
| Rate for Payer: Preferred Network Access Commercial |
$403.77
|
| Rate for Payer: Quartz Beloit One Network |
$215.05
|
| Rate for Payer: Quartz Commercial |
$263.33
|
| Rate for Payer: WEA Trust Commercial |
$241.38
|
| Rate for Payer: WPS Commercial |
$325.07
|
|
|
PLATE SEMI TUBULAR 6HL 222.06
|
Facility
|
IP
|
$447.00
|
|
| Hospital Charge Code |
2966781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$227.79 |
| Max. Negotiated Rate |
$427.69 |
| Rate for Payer: Aetna Commercial |
$418.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.39
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$427.69
|
| Rate for Payer: Health EOS Commercial |
$413.74
|
| Rate for Payer: HFN Commercial |
$427.69
|
| Rate for Payer: Multiplan Commercial |
$371.90
|
| Rate for Payer: Preferred Network Access Commercial |
$427.69
|
| Rate for Payer: Quartz Beloit One Network |
$227.79
|
| Rate for Payer: Quartz Commercial |
$278.93
|
| Rate for Payer: WEA Trust Commercial |
$255.68
|
| Rate for Payer: WPS Commercial |
$344.32
|
|
|
PLATE SEMI TUBULAR 6HL 222.06
|
Facility
|
OP
|
$447.00
|
|
| Hospital Charge Code |
2966781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.17 |
| Max. Negotiated Rate |
$427.69 |
| Rate for Payer: Aetna Commercial |
$418.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.80
|
| Rate for Payer: Aetna Managed Medicare |
$130.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$302.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$232.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$223.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.39
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$427.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$260.15
|
| Rate for Payer: Health EOS Commercial |
$413.74
|
| Rate for Payer: HFN Commercial |
$427.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$348.66
|
| Rate for Payer: Multiplan Commercial |
$371.90
|
| Rate for Payer: NAPHCARE Commercial |
$278.93
|
| Rate for Payer: Preferred Network Access Commercial |
$427.69
|
| Rate for Payer: Quartz Beloit One Network |
$227.79
|
| Rate for Payer: Quartz Commercial |
$302.17
|
| Rate for Payer: Quartz Medicare Advantage |
$278.93
|
| Rate for Payer: The Alliance Commercial |
$232.44
|
| Rate for Payer: WEA Trust Commercial |
$255.68
|
| Rate for Payer: WPS Commercial |
$344.32
|
|
|
PLATE SEMI TUBULAR 7HL 222.07
|
Facility
|
IP
|
$478.00
|
|
| Hospital Charge Code |
2966782
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$243.59 |
| Max. Negotiated Rate |
$457.35 |
| Rate for Payer: Aetna Commercial |
$447.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$427.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.47
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$457.35
|
| Rate for Payer: Health EOS Commercial |
$442.44
|
| Rate for Payer: HFN Commercial |
$457.35
|
| Rate for Payer: Multiplan Commercial |
$397.70
|
| Rate for Payer: Preferred Network Access Commercial |
$457.35
|
| Rate for Payer: Quartz Beloit One Network |
$243.59
|
| Rate for Payer: Quartz Commercial |
$298.27
|
| Rate for Payer: WEA Trust Commercial |
$273.42
|
| Rate for Payer: WPS Commercial |
$368.20
|
|
|
PLATE SEMI TUBULAR 7HL 222.07
|
Facility
|
OP
|
$478.00
|
|
| Hospital Charge Code |
2966782
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$139.19 |
| Max. Negotiated Rate |
$457.35 |
| Rate for Payer: Aetna Commercial |
$447.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$427.52
|
| Rate for Payer: Aetna Managed Medicare |
$139.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$248.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$238.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.47
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$457.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.20
|
| Rate for Payer: Health EOS Commercial |
$442.44
|
| Rate for Payer: HFN Commercial |
$457.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.84
|
| Rate for Payer: Multiplan Commercial |
$397.70
|
| Rate for Payer: NAPHCARE Commercial |
$298.27
|
| Rate for Payer: Preferred Network Access Commercial |
$457.35
|
| Rate for Payer: Quartz Beloit One Network |
$243.59
|
| Rate for Payer: Quartz Commercial |
$323.13
|
| Rate for Payer: Quartz Medicare Advantage |
$298.27
|
| Rate for Payer: The Alliance Commercial |
$248.56
|
| Rate for Payer: WEA Trust Commercial |
$273.42
|
| Rate for Payer: WPS Commercial |
$368.20
|
|
|
PLATE SEMI TUBULAR 8HL 222.08
|
Facility
|
IP
|
$445.00
|
|
| Hospital Charge Code |
2966783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$226.77 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
PLATE SEMI TUBULAR 8HL 222.08
|
Facility
|
OP
|
$445.00
|
|
| Hospital Charge Code |
2966783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$129.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$222.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.99
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.10
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$277.68
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$300.82
|
| Rate for Payer: Quartz Medicare Advantage |
$277.68
|
| Rate for Payer: The Alliance Commercial |
$231.40
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
PLATE SLIM STRAIGHT 3 HOLE 626963
|
Facility
|
OP
|
$5,026.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6173720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,463.57 |
| Max. Negotiated Rate |
$4,808.88 |
| Rate for Payer: Aetna Commercial |
$4,704.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,495.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,463.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,397.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,613.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,508.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,770.33
|
| Rate for Payer: Cash Price |
$1,507.80
|
| Rate for Payer: Cigna Commercial |
$4,808.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,925.13
|
| Rate for Payer: Health EOS Commercial |
$4,652.07
|
| Rate for Payer: HFN Commercial |
$4,808.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,920.28
|
| Rate for Payer: Multiplan Commercial |
$4,181.63
|
| Rate for Payer: NAPHCARE Commercial |
$3,136.22
|
| Rate for Payer: Preferred Network Access Commercial |
$4,808.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,561.25
|
| Rate for Payer: Quartz Commercial |
$3,397.58
|
| Rate for Payer: Quartz Medicare Advantage |
$3,136.22
|
| Rate for Payer: The Alliance Commercial |
$2,613.52
|
| Rate for Payer: WEA Trust Commercial |
$2,874.87
|
| Rate for Payer: WPS Commercial |
$3,871.53
|
|
|
PLATE SLIM STRAIGHT 3 HOLE 626963
|
Facility
|
IP
|
$5,026.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6173720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,561.25 |
| Max. Negotiated Rate |
$4,808.88 |
| Rate for Payer: Aetna Commercial |
$4,704.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,495.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,770.33
|
| Rate for Payer: Cash Price |
$1,507.80
|
| Rate for Payer: Cigna Commercial |
$4,808.88
|
| Rate for Payer: Health EOS Commercial |
$4,652.07
|
| Rate for Payer: HFN Commercial |
$4,808.88
|
| Rate for Payer: Multiplan Commercial |
$4,181.63
|
| Rate for Payer: Preferred Network Access Commercial |
$4,808.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,561.25
|
| Rate for Payer: Quartz Commercial |
$3,136.22
|
| Rate for Payer: WEA Trust Commercial |
$2,874.87
|
| Rate for Payer: WPS Commercial |
$3,871.53
|
|
|
PLATE SLIM STRAIGHT 5 HOLE 626965
|
Facility
|
OP
|
$7,469.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,174.97 |
| Max. Negotiated Rate |
$7,146.34 |
| Rate for Payer: Aetna Commercial |
$6,990.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,680.27
|
| Rate for Payer: Aetna Managed Medicare |
$2,174.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,049.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,883.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,728.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,116.91
|
| Rate for Payer: Cash Price |
$2,240.70
|
| Rate for Payer: Cigna Commercial |
$7,146.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,346.96
|
| Rate for Payer: Health EOS Commercial |
$6,913.31
|
| Rate for Payer: HFN Commercial |
$7,146.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,825.82
|
| Rate for Payer: Multiplan Commercial |
$6,214.21
|
| Rate for Payer: NAPHCARE Commercial |
$4,660.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7,146.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,806.20
|
| Rate for Payer: Quartz Commercial |
$5,049.04
|
| Rate for Payer: Quartz Medicare Advantage |
$4,660.66
|
| Rate for Payer: The Alliance Commercial |
$3,883.88
|
| Rate for Payer: WEA Trust Commercial |
$4,272.27
|
| Rate for Payer: WPS Commercial |
$5,753.37
|
|
|
PLATE SLIM STRAIGHT 5 HOLE 626965
|
Facility
|
IP
|
$7,469.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,806.20 |
| Max. Negotiated Rate |
$7,146.34 |
| Rate for Payer: Aetna Commercial |
$6,990.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,680.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,116.91
|
| Rate for Payer: Cash Price |
$2,240.70
|
| Rate for Payer: Cigna Commercial |
$7,146.34
|
| Rate for Payer: Health EOS Commercial |
$6,913.31
|
| Rate for Payer: HFN Commercial |
$7,146.34
|
| Rate for Payer: Multiplan Commercial |
$6,214.21
|
| Rate for Payer: Preferred Network Access Commercial |
$7,146.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,806.20
|
| Rate for Payer: Quartz Commercial |
$4,660.66
|
| Rate for Payer: WEA Trust Commercial |
$4,272.27
|
| Rate for Payer: WPS Commercial |
$5,753.37
|
|
|
PLATE SLIM STRAIGHT 6 HOLE 626966
|
Facility
|
IP
|
$5,026.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6171787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,561.25 |
| Max. Negotiated Rate |
$4,808.88 |
| Rate for Payer: Aetna Commercial |
$4,704.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,495.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,770.33
|
| Rate for Payer: Cash Price |
$1,507.80
|
| Rate for Payer: Cigna Commercial |
$4,808.88
|
| Rate for Payer: Health EOS Commercial |
$4,652.07
|
| Rate for Payer: HFN Commercial |
$4,808.88
|
| Rate for Payer: Multiplan Commercial |
$4,181.63
|
| Rate for Payer: Preferred Network Access Commercial |
$4,808.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,561.25
|
| Rate for Payer: Quartz Commercial |
$3,136.22
|
| Rate for Payer: WEA Trust Commercial |
$2,874.87
|
| Rate for Payer: WPS Commercial |
$3,871.53
|
|
|
PLATE SLIM STRAIGHT 6 HOLE 626966
|
Facility
|
OP
|
$5,026.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6171787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,463.57 |
| Max. Negotiated Rate |
$4,808.88 |
| Rate for Payer: Aetna Commercial |
$4,704.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,495.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,463.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,397.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,613.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,508.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,770.33
|
| Rate for Payer: Cash Price |
$1,507.80
|
| Rate for Payer: Cigna Commercial |
$4,808.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,925.13
|
| Rate for Payer: Health EOS Commercial |
$4,652.07
|
| Rate for Payer: HFN Commercial |
$4,808.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,920.28
|
| Rate for Payer: Multiplan Commercial |
$4,181.63
|
| Rate for Payer: NAPHCARE Commercial |
$3,136.22
|
| Rate for Payer: Preferred Network Access Commercial |
$4,808.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,561.25
|
| Rate for Payer: Quartz Commercial |
$3,397.58
|
| Rate for Payer: Quartz Medicare Advantage |
$3,136.22
|
| Rate for Payer: The Alliance Commercial |
$2,613.52
|
| Rate for Payer: WEA Trust Commercial |
$2,874.87
|
| Rate for Payer: WPS Commercial |
$3,871.53
|
|
|
PLATE SLIM STRAIGHT 7 HOLE 626967
|
Facility
|
IP
|
$7,469.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,806.20 |
| Max. Negotiated Rate |
$7,146.34 |
| Rate for Payer: Aetna Commercial |
$6,990.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,680.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,116.91
|
| Rate for Payer: Cash Price |
$2,240.70
|
| Rate for Payer: Cigna Commercial |
$7,146.34
|
| Rate for Payer: Health EOS Commercial |
$6,913.31
|
| Rate for Payer: HFN Commercial |
$7,146.34
|
| Rate for Payer: Multiplan Commercial |
$6,214.21
|
| Rate for Payer: Preferred Network Access Commercial |
$7,146.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,806.20
|
| Rate for Payer: Quartz Commercial |
$4,660.66
|
| Rate for Payer: WEA Trust Commercial |
$4,272.27
|
| Rate for Payer: WPS Commercial |
$5,753.37
|
|
|
PLATE SLIM STRAIGHT 7 HOLE 626967
|
Facility
|
OP
|
$7,469.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,174.97 |
| Max. Negotiated Rate |
$7,146.34 |
| Rate for Payer: Aetna Commercial |
$6,990.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,680.27
|
| Rate for Payer: Aetna Managed Medicare |
$2,174.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,049.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,883.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,728.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,116.91
|
| Rate for Payer: Cash Price |
$2,240.70
|
| Rate for Payer: Cigna Commercial |
$7,146.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,346.96
|
| Rate for Payer: Health EOS Commercial |
$6,913.31
|
| Rate for Payer: HFN Commercial |
$7,146.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,825.82
|
| Rate for Payer: Multiplan Commercial |
$6,214.21
|
| Rate for Payer: NAPHCARE Commercial |
$4,660.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7,146.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,806.20
|
| Rate for Payer: Quartz Commercial |
$5,049.04
|
| Rate for Payer: Quartz Medicare Advantage |
$4,660.66
|
| Rate for Payer: The Alliance Commercial |
$3,883.88
|
| Rate for Payer: WEA Trust Commercial |
$4,272.27
|
| Rate for Payer: WPS Commercial |
$5,753.37
|
|
|
PLATE SLIM Y 2 SHAFT HOLE 626982
|
Facility
|
IP
|
$5,456.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,780.38 |
| Max. Negotiated Rate |
$5,220.30 |
| Rate for Payer: Aetna Commercial |
$5,106.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.35
|
| Rate for Payer: Cash Price |
$1,636.80
|
| Rate for Payer: Cigna Commercial |
$5,220.30
|
| Rate for Payer: Health EOS Commercial |
$5,050.07
|
| Rate for Payer: HFN Commercial |
$5,220.30
|
| Rate for Payer: Multiplan Commercial |
$4,539.39
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.30
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.38
|
| Rate for Payer: Quartz Commercial |
$3,404.54
|
| Rate for Payer: WEA Trust Commercial |
$3,120.83
|
| Rate for Payer: WPS Commercial |
$4,202.76
|
|
|
PLATE SLIM Y 2 SHAFT HOLE 626982
|
Facility
|
OP
|
$5,456.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,588.79 |
| Max. Negotiated Rate |
$5,220.30 |
| Rate for Payer: Aetna Commercial |
$5,106.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.85
|
| Rate for Payer: Aetna Managed Medicare |
$1,588.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,688.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,837.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,723.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.35
|
| Rate for Payer: Cash Price |
$1,636.80
|
| Rate for Payer: Cigna Commercial |
$5,220.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,175.39
|
| Rate for Payer: Health EOS Commercial |
$5,050.07
|
| Rate for Payer: HFN Commercial |
$5,220.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,255.68
|
| Rate for Payer: Multiplan Commercial |
$4,539.39
|
| Rate for Payer: NAPHCARE Commercial |
$3,404.54
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.30
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.38
|
| Rate for Payer: Quartz Commercial |
$3,688.26
|
| Rate for Payer: Quartz Medicare Advantage |
$3,404.54
|
| Rate for Payer: The Alliance Commercial |
$2,837.12
|
| Rate for Payer: WEA Trust Commercial |
$3,120.83
|
| Rate for Payer: WPS Commercial |
$4,202.76
|
|
|
PLATE SLIM Y 4 SHAFT HOLE 626984
|
Facility
|
OP
|
$5,456.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,588.79 |
| Max. Negotiated Rate |
$5,220.30 |
| Rate for Payer: Aetna Commercial |
$5,106.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.85
|
| Rate for Payer: Aetna Managed Medicare |
$1,588.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,688.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,837.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,723.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.35
|
| Rate for Payer: Cash Price |
$1,636.80
|
| Rate for Payer: Cigna Commercial |
$5,220.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,175.39
|
| Rate for Payer: Health EOS Commercial |
$5,050.07
|
| Rate for Payer: HFN Commercial |
$5,220.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,255.68
|
| Rate for Payer: Multiplan Commercial |
$4,539.39
|
| Rate for Payer: NAPHCARE Commercial |
$3,404.54
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.30
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.38
|
| Rate for Payer: Quartz Commercial |
$3,688.26
|
| Rate for Payer: Quartz Medicare Advantage |
$3,404.54
|
| Rate for Payer: The Alliance Commercial |
$2,837.12
|
| Rate for Payer: WEA Trust Commercial |
$3,120.83
|
| Rate for Payer: WPS Commercial |
$4,202.76
|
|
|
PLATE SLIM Y 4 SHAFT HOLE 626984
|
Facility
|
IP
|
$5,456.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,780.38 |
| Max. Negotiated Rate |
$5,220.30 |
| Rate for Payer: Aetna Commercial |
$5,106.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.35
|
| Rate for Payer: Cash Price |
$1,636.80
|
| Rate for Payer: Cigna Commercial |
$5,220.30
|
| Rate for Payer: Health EOS Commercial |
$5,050.07
|
| Rate for Payer: HFN Commercial |
$5,220.30
|
| Rate for Payer: Multiplan Commercial |
$4,539.39
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.30
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.38
|
| Rate for Payer: Quartz Commercial |
$3,404.54
|
| Rate for Payer: WEA Trust Commercial |
$3,120.83
|
| Rate for Payer: WPS Commercial |
$4,202.76
|
|
|
PLATE SPIDER 20MM SMALL 814100003
|
Facility
|
IP
|
$726.00
|
|
| Hospital Charge Code |
2965014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$369.97 |
| Max. Negotiated Rate |
$694.64 |
| Rate for Payer: Aetna Commercial |
$679.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$649.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$400.17
|
| Rate for Payer: Cash Price |
$217.80
|
| Rate for Payer: Cigna Commercial |
$694.64
|
| Rate for Payer: Health EOS Commercial |
$671.99
|
| Rate for Payer: HFN Commercial |
$694.64
|
| Rate for Payer: Multiplan Commercial |
$604.03
|
| Rate for Payer: Preferred Network Access Commercial |
$694.64
|
| Rate for Payer: Quartz Beloit One Network |
$369.97
|
| Rate for Payer: Quartz Commercial |
$453.02
|
| Rate for Payer: WEA Trust Commercial |
$415.27
|
| Rate for Payer: WPS Commercial |
$559.24
|
|
|
PLATE SPIDER 20MM SMALL 814100003
|
Facility
|
OP
|
$726.00
|
|
| Hospital Charge Code |
2965014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$211.41 |
| Max. Negotiated Rate |
$694.64 |
| Rate for Payer: Aetna Commercial |
$679.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$649.33
|
| Rate for Payer: Aetna Managed Medicare |
$211.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$490.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$377.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$362.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$400.17
|
| Rate for Payer: Cash Price |
$217.80
|
| Rate for Payer: Cigna Commercial |
$694.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$422.53
|
| Rate for Payer: Health EOS Commercial |
$671.99
|
| Rate for Payer: HFN Commercial |
$694.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$566.28
|
| Rate for Payer: Multiplan Commercial |
$604.03
|
| Rate for Payer: NAPHCARE Commercial |
$453.02
|
| Rate for Payer: Preferred Network Access Commercial |
$694.64
|
| Rate for Payer: Quartz Beloit One Network |
$369.97
|
| Rate for Payer: Quartz Commercial |
$490.78
|
| Rate for Payer: Quartz Medicare Advantage |
$453.02
|
| Rate for Payer: The Alliance Commercial |
$377.52
|
| Rate for Payer: WEA Trust Commercial |
$415.27
|
| Rate for Payer: WPS Commercial |
$559.24
|
|
