|
PLATE LAT/DIS/FIBULA 11H/LT 02.118.413
|
Facility
|
OP
|
$6,110.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,779.23 |
| Max. Negotiated Rate |
$5,846.05 |
| Rate for Payer: Aetna Commercial |
$5,718.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,464.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,779.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,130.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,177.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,050.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,367.83
|
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Cigna Commercial |
$5,846.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,556.02
|
| Rate for Payer: Health EOS Commercial |
$5,655.42
|
| Rate for Payer: HFN Commercial |
$5,846.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,765.80
|
| Rate for Payer: Multiplan Commercial |
$5,083.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,812.64
|
| Rate for Payer: Preferred Network Access Commercial |
$5,846.05
|
| Rate for Payer: Quartz Beloit One Network |
$3,113.66
|
| Rate for Payer: Quartz Commercial |
$4,130.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,812.64
|
| Rate for Payer: The Alliance Commercial |
$3,177.20
|
| Rate for Payer: WEA Trust Commercial |
$3,494.92
|
| Rate for Payer: WPS Commercial |
$4,706.53
|
|
|
PLATE LAT/DIS/FIBULA 13H/LT 02.118.415
|
Facility
|
IP
|
$6,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,258.38 |
| Max. Negotiated Rate |
$6,117.78 |
| Rate for Payer: Aetna Commercial |
$5,984.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,718.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,524.37
|
| Rate for Payer: Cash Price |
$1,918.20
|
| Rate for Payer: Cigna Commercial |
$6,117.78
|
| Rate for Payer: Health EOS Commercial |
$5,918.29
|
| Rate for Payer: HFN Commercial |
$6,117.78
|
| Rate for Payer: Multiplan Commercial |
$5,319.81
|
| Rate for Payer: Preferred Network Access Commercial |
$6,117.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,258.38
|
| Rate for Payer: Quartz Commercial |
$3,989.86
|
| Rate for Payer: WEA Trust Commercial |
$3,657.37
|
| Rate for Payer: WPS Commercial |
$4,925.30
|
|
|
PLATE LAT/DIS/FIBULA 13H/LT 02.118.415
|
Facility
|
OP
|
$6,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,861.93 |
| Max. Negotiated Rate |
$6,117.78 |
| Rate for Payer: Aetna Commercial |
$5,984.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,718.79
|
| Rate for Payer: Aetna Managed Medicare |
$1,861.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,322.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,324.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,191.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,524.37
|
| Rate for Payer: Cash Price |
$1,918.20
|
| Rate for Payer: Cigna Commercial |
$6,117.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,721.31
|
| Rate for Payer: Health EOS Commercial |
$5,918.29
|
| Rate for Payer: HFN Commercial |
$6,117.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,987.32
|
| Rate for Payer: Multiplan Commercial |
$5,319.81
|
| Rate for Payer: NAPHCARE Commercial |
$3,989.86
|
| Rate for Payer: Preferred Network Access Commercial |
$6,117.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,258.38
|
| Rate for Payer: Quartz Commercial |
$4,322.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,989.86
|
| Rate for Payer: The Alliance Commercial |
$3,324.88
|
| Rate for Payer: WEA Trust Commercial |
$3,657.37
|
| Rate for Payer: WPS Commercial |
$4,925.30
|
|
|
PLATE LAT/DIS/FIBULA 13H/RT 02.118.414
|
Facility
|
IP
|
$6,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,258.38 |
| Max. Negotiated Rate |
$6,117.78 |
| Rate for Payer: Aetna Commercial |
$5,984.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,718.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,524.37
|
| Rate for Payer: Cash Price |
$1,918.20
|
| Rate for Payer: Cigna Commercial |
$6,117.78
|
| Rate for Payer: Health EOS Commercial |
$5,918.29
|
| Rate for Payer: HFN Commercial |
$6,117.78
|
| Rate for Payer: Multiplan Commercial |
$5,319.81
|
| Rate for Payer: Preferred Network Access Commercial |
$6,117.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,258.38
|
| Rate for Payer: Quartz Commercial |
$3,989.86
|
| Rate for Payer: WEA Trust Commercial |
$3,657.37
|
| Rate for Payer: WPS Commercial |
$4,925.30
|
|
|
PLATE LAT/DIS/FIBULA 13H/RT 02.118.414
|
Facility
|
OP
|
$6,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,861.93 |
| Max. Negotiated Rate |
$6,117.78 |
| Rate for Payer: Aetna Commercial |
$5,984.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,718.79
|
| Rate for Payer: Aetna Managed Medicare |
$1,861.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,322.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,324.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,191.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,524.37
|
| Rate for Payer: Cash Price |
$1,918.20
|
| Rate for Payer: Cigna Commercial |
$6,117.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,721.31
|
| Rate for Payer: Health EOS Commercial |
$5,918.29
|
| Rate for Payer: HFN Commercial |
$6,117.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,987.32
|
| Rate for Payer: Multiplan Commercial |
$5,319.81
|
| Rate for Payer: NAPHCARE Commercial |
$3,989.86
|
| Rate for Payer: Preferred Network Access Commercial |
$6,117.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,258.38
|
| Rate for Payer: Quartz Commercial |
$4,322.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,989.86
|
| Rate for Payer: The Alliance Commercial |
$3,324.88
|
| Rate for Payer: WEA Trust Commercial |
$3,657.37
|
| Rate for Payer: WPS Commercial |
$4,925.30
|
|
|
PLATE LAT/DIS/FIBULA 6H/RT 02.118.406
|
Facility
|
IP
|
$8,286.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,222.55 |
| Max. Negotiated Rate |
$7,928.04 |
| Rate for Payer: Aetna Commercial |
$7,755.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,411.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,567.24
|
| Rate for Payer: Cash Price |
$2,485.80
|
| Rate for Payer: Cigna Commercial |
$7,928.04
|
| Rate for Payer: Health EOS Commercial |
$7,669.52
|
| Rate for Payer: HFN Commercial |
$7,928.04
|
| Rate for Payer: Multiplan Commercial |
$6,893.95
|
| Rate for Payer: Preferred Network Access Commercial |
$7,928.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,222.55
|
| Rate for Payer: Quartz Commercial |
$5,170.46
|
| Rate for Payer: WEA Trust Commercial |
$4,739.59
|
| Rate for Payer: WPS Commercial |
$6,382.71
|
|
|
PLATE LAT/DIS/FIBULA 6H/RT 02.118.406
|
Facility
|
OP
|
$8,286.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,412.88 |
| Max. Negotiated Rate |
$7,928.04 |
| Rate for Payer: Aetna Commercial |
$7,755.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,411.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,412.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,601.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,308.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,136.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,567.24
|
| Rate for Payer: Cash Price |
$2,485.80
|
| Rate for Payer: Cigna Commercial |
$7,928.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,822.45
|
| Rate for Payer: Health EOS Commercial |
$7,669.52
|
| Rate for Payer: HFN Commercial |
$7,928.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,463.08
|
| Rate for Payer: Multiplan Commercial |
$6,893.95
|
| Rate for Payer: NAPHCARE Commercial |
$5,170.46
|
| Rate for Payer: Preferred Network Access Commercial |
$7,928.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,222.55
|
| Rate for Payer: Quartz Commercial |
$5,601.34
|
| Rate for Payer: Quartz Medicare Advantage |
$5,170.46
|
| Rate for Payer: The Alliance Commercial |
$4,308.72
|
| Rate for Payer: WEA Trust Commercial |
$4,739.59
|
| Rate for Payer: WPS Commercial |
$6,382.71
|
|
|
PLATE LAT/DIS/FIBULA 7H/LT 02.118.409
|
Facility
|
IP
|
$8,365.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,262.80 |
| Max. Negotiated Rate |
$8,003.63 |
| Rate for Payer: Aetna Commercial |
$7,829.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,481.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,610.79
|
| Rate for Payer: Cash Price |
$2,509.50
|
| Rate for Payer: Cigna Commercial |
$8,003.63
|
| Rate for Payer: Health EOS Commercial |
$7,742.64
|
| Rate for Payer: HFN Commercial |
$8,003.63
|
| Rate for Payer: Multiplan Commercial |
$6,959.68
|
| Rate for Payer: Preferred Network Access Commercial |
$8,003.63
|
| Rate for Payer: Quartz Beloit One Network |
$4,262.80
|
| Rate for Payer: Quartz Commercial |
$5,219.76
|
| Rate for Payer: WEA Trust Commercial |
$4,784.78
|
| Rate for Payer: WPS Commercial |
$6,443.56
|
|
|
PLATE LAT/DIS/FIBULA 7H/LT 02.118.409
|
Facility
|
OP
|
$8,365.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4595221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,435.89 |
| Max. Negotiated Rate |
$8,003.63 |
| Rate for Payer: Aetna Commercial |
$7,829.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,481.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,435.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,654.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,349.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,175.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,610.79
|
| Rate for Payer: Cash Price |
$2,509.50
|
| Rate for Payer: Cigna Commercial |
$8,003.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,868.43
|
| Rate for Payer: Health EOS Commercial |
$7,742.64
|
| Rate for Payer: HFN Commercial |
$8,003.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,524.70
|
| Rate for Payer: Multiplan Commercial |
$6,959.68
|
| Rate for Payer: NAPHCARE Commercial |
$5,219.76
|
| Rate for Payer: Preferred Network Access Commercial |
$8,003.63
|
| Rate for Payer: Quartz Beloit One Network |
$4,262.80
|
| Rate for Payer: Quartz Commercial |
$5,654.74
|
| Rate for Payer: Quartz Medicare Advantage |
$5,219.76
|
| Rate for Payer: The Alliance Commercial |
$4,349.80
|
| Rate for Payer: WEA Trust Commercial |
$4,784.78
|
| Rate for Payer: WPS Commercial |
$6,443.56
|
|
|
PLATE LAT/DIS/FIBULA 7H/RT 02.118.408
|
Facility
|
IP
|
$8,365.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520508
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,262.80 |
| Max. Negotiated Rate |
$8,003.63 |
| Rate for Payer: Aetna Commercial |
$7,829.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,481.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,610.79
|
| Rate for Payer: Cash Price |
$2,509.50
|
| Rate for Payer: Cigna Commercial |
$8,003.63
|
| Rate for Payer: Health EOS Commercial |
$7,742.64
|
| Rate for Payer: HFN Commercial |
$8,003.63
|
| Rate for Payer: Multiplan Commercial |
$6,959.68
|
| Rate for Payer: Preferred Network Access Commercial |
$8,003.63
|
| Rate for Payer: Quartz Beloit One Network |
$4,262.80
|
| Rate for Payer: Quartz Commercial |
$5,219.76
|
| Rate for Payer: WEA Trust Commercial |
$4,784.78
|
| Rate for Payer: WPS Commercial |
$6,443.56
|
|
|
PLATE LAT/DIS/FIBULA 7H/RT 02.118.408
|
Facility
|
OP
|
$8,365.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520508
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,435.89 |
| Max. Negotiated Rate |
$8,003.63 |
| Rate for Payer: Aetna Commercial |
$7,829.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,481.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,435.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,654.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,349.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,175.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,610.79
|
| Rate for Payer: Cash Price |
$2,509.50
|
| Rate for Payer: Cigna Commercial |
$8,003.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,868.43
|
| Rate for Payer: Health EOS Commercial |
$7,742.64
|
| Rate for Payer: HFN Commercial |
$8,003.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,524.70
|
| Rate for Payer: Multiplan Commercial |
$6,959.68
|
| Rate for Payer: NAPHCARE Commercial |
$5,219.76
|
| Rate for Payer: Preferred Network Access Commercial |
$8,003.63
|
| Rate for Payer: Quartz Beloit One Network |
$4,262.80
|
| Rate for Payer: Quartz Commercial |
$5,654.74
|
| Rate for Payer: Quartz Medicare Advantage |
$5,219.76
|
| Rate for Payer: The Alliance Commercial |
$4,349.80
|
| Rate for Payer: WEA Trust Commercial |
$4,784.78
|
| Rate for Payer: WPS Commercial |
$6,443.56
|
|
|
PLATE LAT/DIS/FIBULA 9H/LT 02.118.411
|
Facility
|
OP
|
$8,752.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,548.58 |
| Max. Negotiated Rate |
$8,373.91 |
| Rate for Payer: Aetna Commercial |
$8,191.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,827.79
|
| Rate for Payer: Aetna Managed Medicare |
$2,548.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,916.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,551.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,369.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,824.10
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$8,373.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,093.66
|
| Rate for Payer: Health EOS Commercial |
$8,100.85
|
| Rate for Payer: HFN Commercial |
$8,373.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,826.56
|
| Rate for Payer: Multiplan Commercial |
$7,281.66
|
| Rate for Payer: NAPHCARE Commercial |
$5,461.25
|
| Rate for Payer: Preferred Network Access Commercial |
$8,373.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,460.02
|
| Rate for Payer: Quartz Commercial |
$5,916.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,461.25
|
| Rate for Payer: The Alliance Commercial |
$4,551.04
|
| Rate for Payer: WEA Trust Commercial |
$5,006.14
|
| Rate for Payer: WPS Commercial |
$6,741.67
|
|
|
PLATE LAT/DIS/FIBULA 9H/LT 02.118.411
|
Facility
|
IP
|
$8,752.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520514
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,460.02 |
| Max. Negotiated Rate |
$8,373.91 |
| Rate for Payer: Aetna Commercial |
$8,191.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,827.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,824.10
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$8,373.91
|
| Rate for Payer: Health EOS Commercial |
$8,100.85
|
| Rate for Payer: HFN Commercial |
$8,373.91
|
| Rate for Payer: Multiplan Commercial |
$7,281.66
|
| Rate for Payer: Preferred Network Access Commercial |
$8,373.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,460.02
|
| Rate for Payer: Quartz Commercial |
$5,461.25
|
| Rate for Payer: WEA Trust Commercial |
$5,006.14
|
| Rate for Payer: WPS Commercial |
$6,741.67
|
|
|
PLATE LAT/DIS/FIBULA 9H/RT 02.118.410
|
Facility
|
IP
|
$8,752.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,460.02 |
| Max. Negotiated Rate |
$8,373.91 |
| Rate for Payer: Aetna Commercial |
$8,191.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,827.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,824.10
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$8,373.91
|
| Rate for Payer: Health EOS Commercial |
$8,100.85
|
| Rate for Payer: HFN Commercial |
$8,373.91
|
| Rate for Payer: Multiplan Commercial |
$7,281.66
|
| Rate for Payer: Preferred Network Access Commercial |
$8,373.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,460.02
|
| Rate for Payer: Quartz Commercial |
$5,461.25
|
| Rate for Payer: WEA Trust Commercial |
$5,006.14
|
| Rate for Payer: WPS Commercial |
$6,741.67
|
|
|
PLATE LAT/DIS/FIBULA 9H/RT 02.118.410
|
Facility
|
OP
|
$8,752.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4520510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,548.58 |
| Max. Negotiated Rate |
$8,373.91 |
| Rate for Payer: Aetna Commercial |
$8,191.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,827.79
|
| Rate for Payer: Aetna Managed Medicare |
$2,548.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,916.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,551.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,369.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,824.10
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$8,373.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,093.66
|
| Rate for Payer: Health EOS Commercial |
$8,100.85
|
| Rate for Payer: HFN Commercial |
$8,373.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,826.56
|
| Rate for Payer: Multiplan Commercial |
$7,281.66
|
| Rate for Payer: NAPHCARE Commercial |
$5,461.25
|
| Rate for Payer: Preferred Network Access Commercial |
$8,373.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,460.02
|
| Rate for Payer: Quartz Commercial |
$5,916.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,461.25
|
| Rate for Payer: The Alliance Commercial |
$4,551.04
|
| Rate for Payer: WEA Trust Commercial |
$5,006.14
|
| Rate for Payer: WPS Commercial |
$6,741.67
|
|
|
PLATE LATERAL DISTAL FIBULA 2.7/3.5 3HL LT 02.112.137
|
Facility
|
OP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3365524
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
PLATE LATERAL DISTAL FIBULA 2.7/3.5 3HL LT 02.112.137
|
Facility
|
IP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3365524
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
PLATE LATERAL DISTAL FIBULA 5HL LT 02.112.141
|
Facility
|
IP
|
$5,218.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4518955
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,659.09 |
| Max. Negotiated Rate |
$4,992.58 |
| Rate for Payer: Aetna Commercial |
$4,884.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,666.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,876.16
|
| Rate for Payer: Cash Price |
$1,565.40
|
| Rate for Payer: Cigna Commercial |
$4,992.58
|
| Rate for Payer: Health EOS Commercial |
$4,829.78
|
| Rate for Payer: HFN Commercial |
$4,992.58
|
| Rate for Payer: Multiplan Commercial |
$4,341.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,992.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,659.09
|
| Rate for Payer: Quartz Commercial |
$3,256.03
|
| Rate for Payer: WEA Trust Commercial |
$2,984.70
|
| Rate for Payer: WPS Commercial |
$4,019.43
|
|
|
PLATE LATERAL DISTAL FIBULA 5HL LT 02.112.141
|
Facility
|
OP
|
$5,218.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4518955
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,519.48 |
| Max. Negotiated Rate |
$4,992.58 |
| Rate for Payer: Aetna Commercial |
$4,884.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,666.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,519.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,527.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,713.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,604.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,876.16
|
| Rate for Payer: Cash Price |
$1,565.40
|
| Rate for Payer: Cigna Commercial |
$4,992.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,036.88
|
| Rate for Payer: Health EOS Commercial |
$4,829.78
|
| Rate for Payer: HFN Commercial |
$4,992.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,070.04
|
| Rate for Payer: Multiplan Commercial |
$4,341.38
|
| Rate for Payer: NAPHCARE Commercial |
$3,256.03
|
| Rate for Payer: Preferred Network Access Commercial |
$4,992.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,659.09
|
| Rate for Payer: Quartz Commercial |
$3,527.37
|
| Rate for Payer: Quartz Medicare Advantage |
$3,256.03
|
| Rate for Payer: The Alliance Commercial |
$2,713.36
|
| Rate for Payer: WEA Trust Commercial |
$2,984.70
|
| Rate for Payer: WPS Commercial |
$4,019.43
|
|
|
PLATE LATERAL DISTAL FIBULA 7HL RT 02.112.144
|
Facility
|
IP
|
$6,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966370
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,177.36 |
| Max. Negotiated Rate |
$5,965.65 |
| Rate for Payer: Aetna Commercial |
$5,835.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,576.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,436.73
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,965.65
|
| Rate for Payer: Health EOS Commercial |
$5,771.12
|
| Rate for Payer: HFN Commercial |
$5,965.65
|
| Rate for Payer: Multiplan Commercial |
$5,187.52
|
| Rate for Payer: Preferred Network Access Commercial |
$5,965.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.36
|
| Rate for Payer: Quartz Commercial |
$3,890.64
|
| Rate for Payer: WEA Trust Commercial |
$3,566.42
|
| Rate for Payer: WPS Commercial |
$4,802.82
|
|
|
PLATE LATERAL DISTAL FIBULA 7HL RT 02.112.144
|
Facility
|
OP
|
$6,235.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966370
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,815.63 |
| Max. Negotiated Rate |
$5,965.65 |
| Rate for Payer: The Alliance Commercial |
$3,242.20
|
| Rate for Payer: Aetna Commercial |
$5,835.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,576.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,815.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,214.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,242.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,112.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,436.73
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$5,965.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,628.77
|
| Rate for Payer: Health EOS Commercial |
$5,771.12
|
| Rate for Payer: HFN Commercial |
$5,965.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,863.30
|
| Rate for Payer: Multiplan Commercial |
$5,187.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,890.64
|
| Rate for Payer: Preferred Network Access Commercial |
$5,965.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,177.36
|
| Rate for Payer: Quartz Commercial |
$4,214.86
|
| Rate for Payer: Quartz Medicare Advantage |
$3,890.64
|
| Rate for Payer: WEA Trust Commercial |
$3,566.42
|
| Rate for Payer: WPS Commercial |
$4,802.82
|
|
|
PLATE LATERAL FUSION TTC SM RT ORTHOLOC 5920301R
|
Facility
|
IP
|
$11,746.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6201058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,985.76 |
| Max. Negotiated Rate |
$11,238.57 |
| Rate for Payer: Aetna Commercial |
$10,994.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,505.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,474.40
|
| Rate for Payer: Cash Price |
$3,523.80
|
| Rate for Payer: Cigna Commercial |
$11,238.57
|
| Rate for Payer: Health EOS Commercial |
$10,872.10
|
| Rate for Payer: HFN Commercial |
$11,238.57
|
| Rate for Payer: Multiplan Commercial |
$9,772.67
|
| Rate for Payer: Preferred Network Access Commercial |
$11,238.57
|
| Rate for Payer: Quartz Beloit One Network |
$5,985.76
|
| Rate for Payer: Quartz Commercial |
$7,329.50
|
| Rate for Payer: WEA Trust Commercial |
$6,718.71
|
| Rate for Payer: WPS Commercial |
$9,047.94
|
|
|
PLATE LATERAL FUSION TTC SM RT ORTHOLOC 5920301R
|
Facility
|
OP
|
$11,746.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6201058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,420.44 |
| Max. Negotiated Rate |
$11,238.57 |
| Rate for Payer: Aetna Commercial |
$10,994.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,505.62
|
| Rate for Payer: Aetna Managed Medicare |
$3,420.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,940.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,107.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,863.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,474.40
|
| Rate for Payer: Cash Price |
$3,523.80
|
| Rate for Payer: Cigna Commercial |
$11,238.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,836.17
|
| Rate for Payer: Health EOS Commercial |
$10,872.10
|
| Rate for Payer: HFN Commercial |
$11,238.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,161.88
|
| Rate for Payer: Multiplan Commercial |
$9,772.67
|
| Rate for Payer: NAPHCARE Commercial |
$7,329.50
|
| Rate for Payer: Preferred Network Access Commercial |
$11,238.57
|
| Rate for Payer: Quartz Beloit One Network |
$5,985.76
|
| Rate for Payer: Quartz Commercial |
$7,940.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,329.50
|
| Rate for Payer: The Alliance Commercial |
$6,107.92
|
| Rate for Payer: WEA Trust Commercial |
$6,718.71
|
| Rate for Payer: WPS Commercial |
$9,047.94
|
|
|
PLATE L-BUTTRESS 4HL RT 240.44
|
Facility
|
IP
|
$1,588.00
|
|
| Hospital Charge Code |
2966759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.24 |
| Max. Negotiated Rate |
$1,519.40 |
| Rate for Payer: Aetna Commercial |
$1,486.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,420.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$875.31
|
| Rate for Payer: Cash Price |
$476.40
|
| Rate for Payer: Cigna Commercial |
$1,519.40
|
| Rate for Payer: Health EOS Commercial |
$1,469.85
|
| Rate for Payer: HFN Commercial |
$1,519.40
|
| Rate for Payer: Multiplan Commercial |
$1,321.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,519.40
|
| Rate for Payer: Quartz Beloit One Network |
$809.24
|
| Rate for Payer: Quartz Commercial |
$990.91
|
| Rate for Payer: WEA Trust Commercial |
$908.34
|
| Rate for Payer: WPS Commercial |
$1,223.24
|
|
|
PLATE L-BUTTRESS 4HL RT 240.44
|
Facility
|
OP
|
$1,588.00
|
|
| Hospital Charge Code |
2966759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.43 |
| Max. Negotiated Rate |
$1,519.40 |
| Rate for Payer: Aetna Commercial |
$1,486.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,420.31
|
| Rate for Payer: Aetna Managed Medicare |
$462.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,073.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$825.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$792.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$875.31
|
| Rate for Payer: Cash Price |
$476.40
|
| Rate for Payer: Cigna Commercial |
$1,519.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$924.22
|
| Rate for Payer: Health EOS Commercial |
$1,469.85
|
| Rate for Payer: HFN Commercial |
$1,519.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,238.64
|
| Rate for Payer: Multiplan Commercial |
$1,321.22
|
| Rate for Payer: NAPHCARE Commercial |
$990.91
|
| Rate for Payer: Preferred Network Access Commercial |
$1,519.40
|
| Rate for Payer: Quartz Beloit One Network |
$809.24
|
| Rate for Payer: Quartz Commercial |
$1,073.49
|
| Rate for Payer: Quartz Medicare Advantage |
$990.91
|
| Rate for Payer: The Alliance Commercial |
$825.76
|
| Rate for Payer: WEA Trust Commercial |
$908.34
|
| Rate for Payer: WPS Commercial |
$1,223.24
|
|
