|
PLATE LC-DCP 2.0MM 6H/39MM 243.586
|
Facility
|
OP
|
$4,306.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508861
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.91 |
| Max. Negotiated Rate |
$4,119.98 |
| Rate for Payer: Aetna Commercial |
$4,030.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,851.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,253.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,910.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,239.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,149.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,373.47
|
| Rate for Payer: Cash Price |
$1,291.80
|
| Rate for Payer: Cigna Commercial |
$4,119.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,506.09
|
| Rate for Payer: Health EOS Commercial |
$3,985.63
|
| Rate for Payer: HFN Commercial |
$4,119.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,358.68
|
| Rate for Payer: Multiplan Commercial |
$3,582.59
|
| Rate for Payer: NAPHCARE Commercial |
$2,686.94
|
| Rate for Payer: Preferred Network Access Commercial |
$4,119.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,194.34
|
| Rate for Payer: Quartz Commercial |
$2,910.86
|
| Rate for Payer: Quartz Medicare Advantage |
$2,686.94
|
| Rate for Payer: The Alliance Commercial |
$2,239.12
|
| Rate for Payer: WEA Trust Commercial |
$2,463.03
|
| Rate for Payer: WPS Commercial |
$3,316.91
|
|
|
PLATE LC-DCP 2.0MM 6H/39MM 243.586
|
Facility
|
IP
|
$4,306.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508861
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,194.34 |
| Max. Negotiated Rate |
$4,119.98 |
| Rate for Payer: Aetna Commercial |
$4,030.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,851.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,373.47
|
| Rate for Payer: Cash Price |
$1,291.80
|
| Rate for Payer: Cigna Commercial |
$4,119.98
|
| Rate for Payer: Health EOS Commercial |
$3,985.63
|
| Rate for Payer: HFN Commercial |
$4,119.98
|
| Rate for Payer: Multiplan Commercial |
$3,582.59
|
| Rate for Payer: Preferred Network Access Commercial |
$4,119.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,194.34
|
| Rate for Payer: Quartz Commercial |
$2,686.94
|
| Rate for Payer: WEA Trust Commercial |
$2,463.03
|
| Rate for Payer: WPS Commercial |
$3,316.91
|
|
|
PLATE LC-DCP 2.4MM 4HL 249.924
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,707.16 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,090.40
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
PLATE LC-DCP 2.4MM 4HL 249.924
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.52 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Aetna Managed Medicare |
$975.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,264.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,742.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,672.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,949.70
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,613.00
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,264.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,090.40
|
| Rate for Payer: The Alliance Commercial |
$1,742.00
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
PLATE LC-DCP 2.4MM 6HL 249.926
|
Facility
|
OP
|
$5,537.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.37 |
| Max. Negotiated Rate |
$5,297.80 |
| Rate for Payer: Aetna Commercial |
$5,182.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,952.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,612.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,743.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,879.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,764.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,051.99
|
| Rate for Payer: Cash Price |
$1,661.10
|
| Rate for Payer: Cigna Commercial |
$5,297.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,222.53
|
| Rate for Payer: Health EOS Commercial |
$5,125.05
|
| Rate for Payer: HFN Commercial |
$5,297.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,318.86
|
| Rate for Payer: Multiplan Commercial |
$4,606.78
|
| Rate for Payer: NAPHCARE Commercial |
$3,455.09
|
| Rate for Payer: Preferred Network Access Commercial |
$5,297.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,821.66
|
| Rate for Payer: Quartz Commercial |
$3,743.01
|
| Rate for Payer: Quartz Medicare Advantage |
$3,455.09
|
| Rate for Payer: The Alliance Commercial |
$2,879.24
|
| Rate for Payer: WEA Trust Commercial |
$3,167.16
|
| Rate for Payer: WPS Commercial |
$4,265.15
|
|
|
PLATE LC-DCP 2.4MM 6HL 249.926
|
Facility
|
IP
|
$5,537.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,821.66 |
| Max. Negotiated Rate |
$5,297.80 |
| Rate for Payer: Aetna Commercial |
$5,182.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,952.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,051.99
|
| Rate for Payer: Cash Price |
$1,661.10
|
| Rate for Payer: Cigna Commercial |
$5,297.80
|
| Rate for Payer: Health EOS Commercial |
$5,125.05
|
| Rate for Payer: HFN Commercial |
$5,297.80
|
| Rate for Payer: Multiplan Commercial |
$4,606.78
|
| Rate for Payer: Preferred Network Access Commercial |
$5,297.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,821.66
|
| Rate for Payer: Quartz Commercial |
$3,455.09
|
| Rate for Payer: WEA Trust Commercial |
$3,167.16
|
| Rate for Payer: WPS Commercial |
$4,265.15
|
|
|
PLATE LC-DCP 2.4MM 8HL 249.928
|
Facility
|
OP
|
$3,795.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,105.10 |
| Max. Negotiated Rate |
$3,631.06 |
| Rate for Payer: Aetna Commercial |
$3,552.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,105.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,565.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,973.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,894.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.80
|
| Rate for Payer: Cash Price |
$1,138.50
|
| Rate for Payer: Cigna Commercial |
$3,631.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,208.69
|
| Rate for Payer: Health EOS Commercial |
$3,512.65
|
| Rate for Payer: HFN Commercial |
$3,631.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,960.10
|
| Rate for Payer: Multiplan Commercial |
$3,157.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,368.08
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,933.93
|
| Rate for Payer: Quartz Commercial |
$2,565.42
|
| Rate for Payer: Quartz Medicare Advantage |
$2,368.08
|
| Rate for Payer: The Alliance Commercial |
$1,973.40
|
| Rate for Payer: WEA Trust Commercial |
$2,170.74
|
| Rate for Payer: WPS Commercial |
$2,923.29
|
|
|
PLATE LC-DCP 2.4MM 8HL 249.928
|
Facility
|
IP
|
$3,795.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,933.93 |
| Max. Negotiated Rate |
$3,631.06 |
| Rate for Payer: Aetna Commercial |
$3,552.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.80
|
| Rate for Payer: Cash Price |
$1,138.50
|
| Rate for Payer: Cigna Commercial |
$3,631.06
|
| Rate for Payer: Health EOS Commercial |
$3,512.65
|
| Rate for Payer: HFN Commercial |
$3,631.06
|
| Rate for Payer: Multiplan Commercial |
$3,157.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,933.93
|
| Rate for Payer: Quartz Commercial |
$2,368.08
|
| Rate for Payer: WEA Trust Commercial |
$2,170.74
|
| Rate for Payer: WPS Commercial |
$2,923.29
|
|
|
PLATE LCP 1.5MM 6HL WITH GUIDES 02.114.504S
|
Facility
|
IP
|
$3,694.00
|
|
| Hospital Charge Code |
2966316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,882.46 |
| Max. Negotiated Rate |
$3,534.42 |
| Rate for Payer: Aetna Commercial |
$3,457.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,303.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.13
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cigna Commercial |
$3,534.42
|
| Rate for Payer: Health EOS Commercial |
$3,419.17
|
| Rate for Payer: HFN Commercial |
$3,534.42
|
| Rate for Payer: Multiplan Commercial |
$3,073.41
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.42
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.46
|
| Rate for Payer: Quartz Commercial |
$2,305.06
|
| Rate for Payer: WEA Trust Commercial |
$2,112.97
|
| Rate for Payer: WPS Commercial |
$2,845.49
|
|
|
PLATE LCP 1.5MM 6HL WITH GUIDES 02.114.504S
|
Facility
|
OP
|
$3,694.00
|
|
| Hospital Charge Code |
2966316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.69 |
| Max. Negotiated Rate |
$3,534.42 |
| Rate for Payer: Aetna Commercial |
$3,457.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,303.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,075.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,497.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,920.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,844.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.13
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cigna Commercial |
$3,534.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,149.91
|
| Rate for Payer: Health EOS Commercial |
$3,419.17
|
| Rate for Payer: HFN Commercial |
$3,534.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,881.32
|
| Rate for Payer: Multiplan Commercial |
$3,073.41
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.06
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.42
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.46
|
| Rate for Payer: Quartz Commercial |
$2,497.14
|
| Rate for Payer: Quartz Medicare Advantage |
$2,305.06
|
| Rate for Payer: The Alliance Commercial |
$1,920.88
|
| Rate for Payer: WEA Trust Commercial |
$2,112.97
|
| Rate for Payer: WPS Commercial |
$2,845.49
|
|
|
PLATE LCP 2.0 10HL 247.360
|
Facility
|
IP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,134.88 |
| Max. Negotiated Rate |
$2,130.79 |
| Rate for Payer: Aetna Commercial |
$2,084.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,991.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,227.52
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,130.79
|
| Rate for Payer: Health EOS Commercial |
$2,061.31
|
| Rate for Payer: HFN Commercial |
$2,130.79
|
| Rate for Payer: Multiplan Commercial |
$1,852.86
|
| Rate for Payer: Preferred Network Access Commercial |
$2,130.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,134.88
|
| Rate for Payer: Quartz Commercial |
$1,389.65
|
| Rate for Payer: WEA Trust Commercial |
$1,273.84
|
| Rate for Payer: WPS Commercial |
$1,715.46
|
|
|
PLATE LCP 2.0 10HL 247.360
|
Facility
|
OP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$648.50 |
| Max. Negotiated Rate |
$2,130.79 |
| Rate for Payer: Aetna Commercial |
$2,084.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,991.83
|
| Rate for Payer: Aetna Managed Medicare |
$648.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,505.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,158.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,111.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,227.52
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,130.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,296.11
|
| Rate for Payer: Health EOS Commercial |
$2,061.31
|
| Rate for Payer: HFN Commercial |
$2,130.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,737.06
|
| Rate for Payer: Multiplan Commercial |
$1,852.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,389.65
|
| Rate for Payer: Preferred Network Access Commercial |
$2,130.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,134.88
|
| Rate for Payer: Quartz Commercial |
$1,505.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,389.65
|
| Rate for Payer: The Alliance Commercial |
$1,158.04
|
| Rate for Payer: WEA Trust Commercial |
$1,273.84
|
| Rate for Payer: WPS Commercial |
$1,715.46
|
|
|
PLATE LCP 2.0 4HL 247.344
|
Facility
|
OP
|
$3,929.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966322
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,144.12 |
| Max. Negotiated Rate |
$3,759.27 |
| Rate for Payer: Aetna Commercial |
$3,677.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,514.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,144.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,656.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,043.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,961.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,165.66
|
| Rate for Payer: Cash Price |
$1,178.70
|
| Rate for Payer: Cigna Commercial |
$3,759.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,286.68
|
| Rate for Payer: Health EOS Commercial |
$3,636.68
|
| Rate for Payer: HFN Commercial |
$3,759.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,064.62
|
| Rate for Payer: Multiplan Commercial |
$3,268.93
|
| Rate for Payer: NAPHCARE Commercial |
$2,451.70
|
| Rate for Payer: Preferred Network Access Commercial |
$3,759.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,002.22
|
| Rate for Payer: Quartz Commercial |
$2,656.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,451.70
|
| Rate for Payer: The Alliance Commercial |
$2,043.08
|
| Rate for Payer: WEA Trust Commercial |
$2,247.39
|
| Rate for Payer: WPS Commercial |
$3,026.51
|
|
|
PLATE LCP 2.0 4HL 247.344
|
Facility
|
IP
|
$3,929.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966322
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.22 |
| Max. Negotiated Rate |
$3,759.27 |
| Rate for Payer: Aetna Commercial |
$3,677.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,514.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,165.66
|
| Rate for Payer: Cash Price |
$1,178.70
|
| Rate for Payer: Cigna Commercial |
$3,759.27
|
| Rate for Payer: Health EOS Commercial |
$3,636.68
|
| Rate for Payer: HFN Commercial |
$3,759.27
|
| Rate for Payer: Multiplan Commercial |
$3,268.93
|
| Rate for Payer: Preferred Network Access Commercial |
$3,759.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,002.22
|
| Rate for Payer: Quartz Commercial |
$2,451.70
|
| Rate for Payer: WEA Trust Commercial |
$2,247.39
|
| Rate for Payer: WPS Commercial |
$3,026.51
|
|
|
PLATE LCP 2.0 5HL 247.345
|
Facility
|
IP
|
$3,039.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,548.67 |
| Max. Negotiated Rate |
$2,907.72 |
| Rate for Payer: Aetna Commercial |
$2,844.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,718.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,675.10
|
| Rate for Payer: Cash Price |
$911.70
|
| Rate for Payer: Cigna Commercial |
$2,907.72
|
| Rate for Payer: Health EOS Commercial |
$2,812.90
|
| Rate for Payer: HFN Commercial |
$2,907.72
|
| Rate for Payer: Multiplan Commercial |
$2,528.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,907.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,548.67
|
| Rate for Payer: Quartz Commercial |
$1,896.34
|
| Rate for Payer: WEA Trust Commercial |
$1,738.31
|
| Rate for Payer: WPS Commercial |
$2,340.94
|
|
|
PLATE LCP 2.0 5HL 247.345
|
Facility
|
OP
|
$3,039.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.96 |
| Max. Negotiated Rate |
$2,907.72 |
| Rate for Payer: Aetna Commercial |
$2,844.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,718.08
|
| Rate for Payer: Aetna Managed Medicare |
$884.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,054.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,580.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,517.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,675.10
|
| Rate for Payer: Cash Price |
$911.70
|
| Rate for Payer: Cigna Commercial |
$2,907.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,768.70
|
| Rate for Payer: Health EOS Commercial |
$2,812.90
|
| Rate for Payer: HFN Commercial |
$2,907.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,370.42
|
| Rate for Payer: Multiplan Commercial |
$2,528.45
|
| Rate for Payer: NAPHCARE Commercial |
$1,896.34
|
| Rate for Payer: Preferred Network Access Commercial |
$2,907.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,548.67
|
| Rate for Payer: Quartz Commercial |
$2,054.36
|
| Rate for Payer: Quartz Medicare Advantage |
$1,896.34
|
| Rate for Payer: The Alliance Commercial |
$1,580.28
|
| Rate for Payer: WEA Trust Commercial |
$1,738.31
|
| Rate for Payer: WPS Commercial |
$2,340.94
|
|
|
PLATE LCP 2.0 6HL 247.346
|
Facility
|
OP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$648.50 |
| Max. Negotiated Rate |
$2,130.79 |
| Rate for Payer: Aetna Commercial |
$2,084.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,991.83
|
| Rate for Payer: Aetna Managed Medicare |
$648.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,505.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,158.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,111.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,227.52
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,130.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,296.11
|
| Rate for Payer: Health EOS Commercial |
$2,061.31
|
| Rate for Payer: HFN Commercial |
$2,130.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,737.06
|
| Rate for Payer: Multiplan Commercial |
$1,852.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,389.65
|
| Rate for Payer: Preferred Network Access Commercial |
$2,130.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,134.88
|
| Rate for Payer: Quartz Commercial |
$1,505.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,389.65
|
| Rate for Payer: The Alliance Commercial |
$1,158.04
|
| Rate for Payer: WEA Trust Commercial |
$1,273.84
|
| Rate for Payer: WPS Commercial |
$1,715.46
|
|
|
PLATE LCP 2.0 6HL 247.346
|
Facility
|
IP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,134.88 |
| Max. Negotiated Rate |
$2,130.79 |
| Rate for Payer: Aetna Commercial |
$2,084.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,991.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,227.52
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,130.79
|
| Rate for Payer: Health EOS Commercial |
$2,061.31
|
| Rate for Payer: HFN Commercial |
$2,130.79
|
| Rate for Payer: Multiplan Commercial |
$1,852.86
|
| Rate for Payer: Preferred Network Access Commercial |
$2,130.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,134.88
|
| Rate for Payer: Quartz Commercial |
$1,389.65
|
| Rate for Payer: WEA Trust Commercial |
$1,273.84
|
| Rate for Payer: WPS Commercial |
$1,715.46
|
|
|
PLATE LCP 2.0 7HL 247.347
|
Facility
|
OP
|
$2,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$623.46 |
| Max. Negotiated Rate |
$2,048.51 |
| Rate for Payer: Aetna Commercial |
$2,003.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,914.91
|
| Rate for Payer: Aetna Managed Medicare |
$623.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,447.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,113.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,068.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,180.12
|
| Rate for Payer: Cash Price |
$642.30
|
| Rate for Payer: Cigna Commercial |
$2,048.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,246.06
|
| Rate for Payer: Health EOS Commercial |
$1,981.71
|
| Rate for Payer: HFN Commercial |
$2,048.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,669.98
|
| Rate for Payer: Multiplan Commercial |
$1,781.31
|
| Rate for Payer: NAPHCARE Commercial |
$1,335.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,048.51
|
| Rate for Payer: Quartz Beloit One Network |
$1,091.05
|
| Rate for Payer: Quartz Commercial |
$1,447.32
|
| Rate for Payer: Quartz Medicare Advantage |
$1,335.98
|
| Rate for Payer: The Alliance Commercial |
$1,113.32
|
| Rate for Payer: WEA Trust Commercial |
$1,224.65
|
| Rate for Payer: WPS Commercial |
$1,649.21
|
|
|
PLATE LCP 2.0 7HL 247.347
|
Facility
|
IP
|
$2,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,091.05 |
| Max. Negotiated Rate |
$2,048.51 |
| Rate for Payer: Aetna Commercial |
$2,003.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,914.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,180.12
|
| Rate for Payer: Cash Price |
$642.30
|
| Rate for Payer: Cigna Commercial |
$2,048.51
|
| Rate for Payer: Health EOS Commercial |
$1,981.71
|
| Rate for Payer: HFN Commercial |
$2,048.51
|
| Rate for Payer: Multiplan Commercial |
$1,781.31
|
| Rate for Payer: Preferred Network Access Commercial |
$2,048.51
|
| Rate for Payer: Quartz Beloit One Network |
$1,091.05
|
| Rate for Payer: Quartz Commercial |
$1,335.98
|
| Rate for Payer: WEA Trust Commercial |
$1,224.65
|
| Rate for Payer: WPS Commercial |
$1,649.21
|
|
|
PLATE LCP 2.0 8HL 247.348
|
Facility
|
OP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$648.50 |
| Max. Negotiated Rate |
$2,130.79 |
| Rate for Payer: Aetna Commercial |
$2,084.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,991.83
|
| Rate for Payer: Aetna Managed Medicare |
$648.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,505.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,158.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,111.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,227.52
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,130.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,296.11
|
| Rate for Payer: Health EOS Commercial |
$2,061.31
|
| Rate for Payer: HFN Commercial |
$2,130.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,737.06
|
| Rate for Payer: Multiplan Commercial |
$1,852.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,389.65
|
| Rate for Payer: Preferred Network Access Commercial |
$2,130.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,134.88
|
| Rate for Payer: Quartz Commercial |
$1,505.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,389.65
|
| Rate for Payer: The Alliance Commercial |
$1,158.04
|
| Rate for Payer: WEA Trust Commercial |
$1,273.84
|
| Rate for Payer: WPS Commercial |
$1,715.46
|
|
|
PLATE LCP 2.0 8HL 247.348
|
Facility
|
IP
|
$2,227.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,134.88 |
| Max. Negotiated Rate |
$2,130.79 |
| Rate for Payer: Aetna Commercial |
$2,084.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,991.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,227.52
|
| Rate for Payer: Cash Price |
$668.10
|
| Rate for Payer: Cigna Commercial |
$2,130.79
|
| Rate for Payer: Health EOS Commercial |
$2,061.31
|
| Rate for Payer: HFN Commercial |
$2,130.79
|
| Rate for Payer: Multiplan Commercial |
$1,852.86
|
| Rate for Payer: Preferred Network Access Commercial |
$2,130.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,134.88
|
| Rate for Payer: Quartz Commercial |
$1,389.65
|
| Rate for Payer: WEA Trust Commercial |
$1,273.84
|
| Rate for Payer: WPS Commercial |
$1,715.46
|
|
|
PLATE LCP ADAPTION 2.0 12HL 247.362
|
Facility
|
OP
|
$4,923.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,433.58 |
| Max. Negotiated Rate |
$4,710.33 |
| Rate for Payer: Aetna Commercial |
$4,607.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,403.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,433.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,327.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,559.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,457.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,713.56
|
| Rate for Payer: Cash Price |
$1,476.90
|
| Rate for Payer: Cigna Commercial |
$4,710.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,865.19
|
| Rate for Payer: Health EOS Commercial |
$4,556.73
|
| Rate for Payer: HFN Commercial |
$4,710.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,839.94
|
| Rate for Payer: Multiplan Commercial |
$4,095.94
|
| Rate for Payer: NAPHCARE Commercial |
$3,071.95
|
| Rate for Payer: Preferred Network Access Commercial |
$4,710.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,508.76
|
| Rate for Payer: Quartz Commercial |
$3,327.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,071.95
|
| Rate for Payer: The Alliance Commercial |
$2,559.96
|
| Rate for Payer: WEA Trust Commercial |
$2,815.96
|
| Rate for Payer: WPS Commercial |
$3,792.19
|
|
|
PLATE LCP ADAPTION 2.0 12HL 247.362
|
Facility
|
IP
|
$4,923.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,508.76 |
| Max. Negotiated Rate |
$4,710.33 |
| Rate for Payer: Aetna Commercial |
$4,607.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,403.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,713.56
|
| Rate for Payer: Cash Price |
$1,476.90
|
| Rate for Payer: Cigna Commercial |
$4,710.33
|
| Rate for Payer: Health EOS Commercial |
$4,556.73
|
| Rate for Payer: HFN Commercial |
$4,710.33
|
| Rate for Payer: Multiplan Commercial |
$4,095.94
|
| Rate for Payer: Preferred Network Access Commercial |
$4,710.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,508.76
|
| Rate for Payer: Quartz Commercial |
$3,071.95
|
| Rate for Payer: WEA Trust Commercial |
$2,815.96
|
| Rate for Payer: WPS Commercial |
$3,792.19
|
|
|
Platelet Antibody, Direct IgG
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
CPT 86023
|
| Hospital Charge Code |
4500769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Aetna Commercial |
$123.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Aetna Managed Medicare |
$12.96
|
| Rate for Payer: Anthem Medicare Advantage |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.96
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$123.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$65.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.96
|
| Rate for Payer: Health EOS Commercial |
$118.30
|
| Rate for Payer: HFN Commercial |
$123.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.96
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$19.44
|
| Rate for Payer: Preferred Network Access Commercial |
$123.50
|
| Rate for Payer: Quartz Beloit One Network |
$57.20
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$12.96
|
| Rate for Payer: The Alliance Commercial |
$51.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.96
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$57.02
|
|
