|
PLATE MTP RIGHT ORTHOLOC 3Di CROSSCHECK 5820MPX1R
|
Facility
|
IP
|
$14,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458985
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,228.17 |
| Max. Negotiated Rate |
$13,571.25 |
| Rate for Payer: Aetna Commercial |
$13,276.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,686.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,818.22
|
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Cigna Commercial |
$13,571.25
|
| Rate for Payer: Health EOS Commercial |
$13,128.71
|
| Rate for Payer: HFN Commercial |
$13,571.25
|
| Rate for Payer: Multiplan Commercial |
$11,801.09
|
| Rate for Payer: Preferred Network Access Commercial |
$13,571.25
|
| Rate for Payer: Quartz Beloit One Network |
$7,228.17
|
| Rate for Payer: Quartz Commercial |
$8,850.82
|
| Rate for Payer: WEA Trust Commercial |
$8,113.25
|
| Rate for Payer: WPS Commercial |
$10,925.94
|
|
|
PLATE NARROW LCP 10HL 224.601
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 10HL 224.601
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 12HL 224.621
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 12HL 224.621
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 4HL 224.541
|
Facility
|
IP
|
$5,040.00
|
|
| Hospital Charge Code |
2966766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.38 |
| Max. Negotiated Rate |
$4,822.27 |
| Rate for Payer: Aetna Commercial |
$4,717.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,507.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.05
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna Commercial |
$4,822.27
|
| Rate for Payer: Health EOS Commercial |
$4,665.02
|
| Rate for Payer: HFN Commercial |
$4,822.27
|
| Rate for Payer: Multiplan Commercial |
$4,193.28
|
| Rate for Payer: Preferred Network Access Commercial |
$4,822.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.38
|
| Rate for Payer: Quartz Commercial |
$3,144.96
|
| Rate for Payer: WEA Trust Commercial |
$2,882.88
|
| Rate for Payer: WPS Commercial |
$3,882.31
|
|
|
PLATE NARROW LCP 4HL 224.541
|
Facility
|
OP
|
$5,040.00
|
|
| Hospital Charge Code |
2966766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.65 |
| Max. Negotiated Rate |
$4,822.27 |
| Rate for Payer: Aetna Commercial |
$4,717.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,507.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,620.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,515.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.05
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna Commercial |
$4,822.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.28
|
| Rate for Payer: Health EOS Commercial |
$4,665.02
|
| Rate for Payer: HFN Commercial |
$4,822.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.20
|
| Rate for Payer: Multiplan Commercial |
$4,193.28
|
| Rate for Payer: NAPHCARE Commercial |
$3,144.96
|
| Rate for Payer: Preferred Network Access Commercial |
$4,822.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.38
|
| Rate for Payer: Quartz Commercial |
$3,407.04
|
| Rate for Payer: Quartz Medicare Advantage |
$3,144.96
|
| Rate for Payer: The Alliance Commercial |
$2,620.80
|
| Rate for Payer: WEA Trust Commercial |
$2,882.88
|
| Rate for Payer: WPS Commercial |
$3,882.31
|
|
|
PLATE NARROW LCP 5HL 224.551
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 5HL 224.551
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 6HL 224.561
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 6HL 224.561
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 7HL 224.571
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 7HL 224.571
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 8HL 224.581
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 8HL 224.581
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 9HL 224.591
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,467.94 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Aetna Managed Medicare |
$1,467.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,407.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,621.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,516.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,933.86
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,931.98
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,145.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,407.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,145.58
|
| Rate for Payer: The Alliance Commercial |
$2,621.32
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NARROW LCP 9HL 224.591
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,568.89 |
| Max. Negotiated Rate |
$4,823.23 |
| Rate for Payer: Aetna Commercial |
$4,718.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,508.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,778.60
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,823.23
|
| Rate for Payer: Health EOS Commercial |
$4,665.95
|
| Rate for Payer: HFN Commercial |
$4,823.23
|
| Rate for Payer: Multiplan Commercial |
$4,194.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,823.23
|
| Rate for Payer: Quartz Beloit One Network |
$2,568.89
|
| Rate for Payer: Quartz Commercial |
$3,145.58
|
| Rate for Payer: WEA Trust Commercial |
$2,883.45
|
| Rate for Payer: WPS Commercial |
$3,883.08
|
|
|
PLATE NCM SHORT/RIGHT 9 HL 626772
|
Facility
|
IP
|
$6,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5861715
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,424.51 |
| Max. Negotiated Rate |
$6,429.70 |
| Rate for Payer: Aetna Commercial |
$6,289.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,010.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,704.06
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Cigna Commercial |
$6,429.70
|
| Rate for Payer: Health EOS Commercial |
$6,220.03
|
| Rate for Payer: HFN Commercial |
$6,429.70
|
| Rate for Payer: Multiplan Commercial |
$5,591.04
|
| Rate for Payer: Preferred Network Access Commercial |
$6,429.70
|
| Rate for Payer: Quartz Beloit One Network |
$3,424.51
|
| Rate for Payer: Quartz Commercial |
$4,193.28
|
| Rate for Payer: WEA Trust Commercial |
$3,843.84
|
| Rate for Payer: WPS Commercial |
$5,176.42
|
|
|
PLATE NCM SHORT/RIGHT 9 HL 626772
|
Facility
|
OP
|
$6,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5861715
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,956.86 |
| Max. Negotiated Rate |
$6,429.70 |
| Rate for Payer: Aetna Commercial |
$6,289.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,010.37
|
| Rate for Payer: Aetna Managed Medicare |
$1,956.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,542.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,494.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,354.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,704.06
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Cigna Commercial |
$6,429.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,911.04
|
| Rate for Payer: Health EOS Commercial |
$6,220.03
|
| Rate for Payer: HFN Commercial |
$6,429.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,241.60
|
| Rate for Payer: Multiplan Commercial |
$5,591.04
|
| Rate for Payer: NAPHCARE Commercial |
$4,193.28
|
| Rate for Payer: Preferred Network Access Commercial |
$6,429.70
|
| Rate for Payer: Quartz Beloit One Network |
$3,424.51
|
| Rate for Payer: Quartz Commercial |
$4,542.72
|
| Rate for Payer: Quartz Medicare Advantage |
$4,193.28
|
| Rate for Payer: The Alliance Commercial |
$3,494.40
|
| Rate for Payer: WEA Trust Commercial |
$3,843.84
|
| Rate for Payer: WPS Commercial |
$5,176.42
|
|
|
PLATE OBLIQ LT T 3H 3H 241.931
|
Facility
|
IP
|
$1,514.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$771.53 |
| Max. Negotiated Rate |
$1,448.60 |
| Rate for Payer: Aetna Commercial |
$1,417.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,354.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$834.52
|
| Rate for Payer: Cash Price |
$454.20
|
| Rate for Payer: Cigna Commercial |
$1,448.60
|
| Rate for Payer: Health EOS Commercial |
$1,401.36
|
| Rate for Payer: HFN Commercial |
$1,448.60
|
| Rate for Payer: Multiplan Commercial |
$1,259.65
|
| Rate for Payer: Preferred Network Access Commercial |
$1,448.60
|
| Rate for Payer: Quartz Beloit One Network |
$771.53
|
| Rate for Payer: Quartz Commercial |
$944.74
|
| Rate for Payer: WEA Trust Commercial |
$866.01
|
| Rate for Payer: WPS Commercial |
$1,166.23
|
|
|
PLATE OBLIQ LT T 3H 3H 241.931
|
Facility
|
OP
|
$1,514.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$440.88 |
| Max. Negotiated Rate |
$1,448.60 |
| Rate for Payer: Aetna Commercial |
$1,417.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,354.12
|
| Rate for Payer: Aetna Managed Medicare |
$440.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,023.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$787.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$755.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$834.52
|
| Rate for Payer: Cash Price |
$454.20
|
| Rate for Payer: Cigna Commercial |
$1,448.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$881.15
|
| Rate for Payer: Health EOS Commercial |
$1,401.36
|
| Rate for Payer: HFN Commercial |
$1,448.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,180.92
|
| Rate for Payer: Multiplan Commercial |
$1,259.65
|
| Rate for Payer: NAPHCARE Commercial |
$944.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,448.60
|
| Rate for Payer: Quartz Beloit One Network |
$771.53
|
| Rate for Payer: Quartz Commercial |
$1,023.46
|
| Rate for Payer: Quartz Medicare Advantage |
$944.74
|
| Rate for Payer: The Alliance Commercial |
$787.28
|
| Rate for Payer: WEA Trust Commercial |
$866.01
|
| Rate for Payer: WPS Commercial |
$1,166.23
|
|
|
PLATE OBLIQ LT T 3H 4H 241.941
|
Facility
|
IP
|
$1,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$810.77 |
| Max. Negotiated Rate |
$1,522.27 |
| Rate for Payer: Aetna Commercial |
$1,489.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,422.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$876.96
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,522.27
|
| Rate for Payer: Health EOS Commercial |
$1,472.63
|
| Rate for Payer: HFN Commercial |
$1,522.27
|
| Rate for Payer: Multiplan Commercial |
$1,323.71
|
| Rate for Payer: Preferred Network Access Commercial |
$1,522.27
|
| Rate for Payer: Quartz Beloit One Network |
$810.77
|
| Rate for Payer: Quartz Commercial |
$992.78
|
| Rate for Payer: WEA Trust Commercial |
$910.05
|
| Rate for Payer: WPS Commercial |
$1,225.55
|
|
|
PLATE OBLIQ LT T 3H 4H 241.941
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$463.30 |
| Max. Negotiated Rate |
$1,522.27 |
| Rate for Payer: Aetna Commercial |
$1,489.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,422.99
|
| Rate for Payer: Aetna Managed Medicare |
$463.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,075.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$827.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$794.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$876.96
|
| Rate for Payer: Cash Price |
$477.30
|
| Rate for Payer: Cigna Commercial |
$1,522.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$925.96
|
| Rate for Payer: Health EOS Commercial |
$1,472.63
|
| Rate for Payer: HFN Commercial |
$1,522.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,240.98
|
| Rate for Payer: Multiplan Commercial |
$1,323.71
|
| Rate for Payer: NAPHCARE Commercial |
$992.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,522.27
|
| Rate for Payer: Quartz Beloit One Network |
$810.77
|
| Rate for Payer: Quartz Commercial |
$1,075.52
|
| Rate for Payer: Quartz Medicare Advantage |
$992.78
|
| Rate for Payer: The Alliance Commercial |
$827.32
|
| Rate for Payer: WEA Trust Commercial |
$910.05
|
| Rate for Payer: WPS Commercial |
$1,225.55
|
|
|
PLATE OBLIQ LT T 3H 5H 241.951
|
Facility
|
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$480.48 |
| Max. Negotiated Rate |
$1,578.72 |
| Rate for Payer: Aetna Commercial |
$1,544.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,475.76
|
| Rate for Payer: Aetna Managed Medicare |
$480.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,115.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$858.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$823.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$909.48
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$1,578.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$960.30
|
| Rate for Payer: Health EOS Commercial |
$1,527.24
|
| Rate for Payer: HFN Commercial |
$1,578.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,287.00
|
| Rate for Payer: Multiplan Commercial |
$1,372.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,029.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,578.72
|
| Rate for Payer: Quartz Beloit One Network |
$840.84
|
| Rate for Payer: Quartz Commercial |
$1,115.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,029.60
|
| Rate for Payer: The Alliance Commercial |
$858.00
|
| Rate for Payer: WEA Trust Commercial |
$943.80
|
| Rate for Payer: WPS Commercial |
$1,270.99
|
|
|
PLATE OBLIQ LT T 3H 5H 241.951
|
Facility
|
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.84 |
| Max. Negotiated Rate |
$1,578.72 |
| Rate for Payer: Aetna Commercial |
$1,544.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,475.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$909.48
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$1,578.72
|
| Rate for Payer: Health EOS Commercial |
$1,527.24
|
| Rate for Payer: HFN Commercial |
$1,578.72
|
| Rate for Payer: Multiplan Commercial |
$1,372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,578.72
|
| Rate for Payer: Quartz Beloit One Network |
$840.84
|
| Rate for Payer: Quartz Commercial |
$1,029.60
|
| Rate for Payer: WEA Trust Commercial |
$943.80
|
| Rate for Payer: WPS Commercial |
$1,270.99
|
|
