|
PLATE MATRIX MANDIBLE RECONSTRUCTION 2.5MM 12HL 04.503.737
|
Facility
|
IP
|
$9,121.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,469.29 |
| Max. Negotiated Rate |
$8,391.32 |
| Rate for Payer: Aetna Commercial |
$8,208.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.13
|
| Rate for Payer: Cash Price |
$2,736.30
|
| Rate for Payer: Cigna Commercial |
$8,391.32
|
| Rate for Payer: Health EOS Commercial |
$8,117.69
|
| Rate for Payer: HFN Commercial |
$8,391.32
|
| Rate for Payer: Multiplan Commercial |
$7,296.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,472.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,391.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.29
|
| Rate for Payer: Quartz Commercial |
$5,472.60
|
| Rate for Payer: WEA Trust Commercial |
$5,016.55
|
| Rate for Payer: WPS Commercial |
$6,755.92
|
|
|
PLATE MATRIX MANDIBLE RECONSTRUCTION 2.5MM 12HL 04.503.737
|
Facility
|
OP
|
$9,121.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,553.88 |
| Max. Negotiated Rate |
$36,484.00 |
| Rate for Payer: Aetna Commercial |
$8,208.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,553.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,928.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,560.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,378.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.13
|
| Rate for Payer: Cash Price |
$2,736.30
|
| Rate for Payer: Cigna Commercial |
$8,391.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,104.11
|
| Rate for Payer: Health EOS Commercial |
$8,117.69
|
| Rate for Payer: HFN Commercial |
$8,391.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,840.75
|
| Rate for Payer: Multiplan Commercial |
$7,296.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,472.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,391.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.29
|
| Rate for Payer: Quartz Commercial |
$5,928.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,472.60
|
| Rate for Payer: The Alliance Commercial |
$36,484.00
|
| Rate for Payer: WEA Trust Commercial |
$5,016.55
|
| Rate for Payer: WPS Commercial |
$6,755.92
|
|
|
PLATE MATRIX WAVE MMF 10HL SHORT 04.503.820
|
Facility
|
OP
|
$4,778.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,337.84 |
| Max. Negotiated Rate |
$19,112.00 |
| Rate for Payer: Aetna Commercial |
$4,300.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,109.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,337.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,105.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,389.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,293.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,532.34
|
| Rate for Payer: Cash Price |
$1,433.40
|
| Rate for Payer: Cigna Commercial |
$4,395.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,673.77
|
| Rate for Payer: Health EOS Commercial |
$4,252.42
|
| Rate for Payer: HFN Commercial |
$4,395.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,583.50
|
| Rate for Payer: Multiplan Commercial |
$3,822.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,866.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,395.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,341.22
|
| Rate for Payer: Quartz Commercial |
$3,105.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,866.80
|
| Rate for Payer: The Alliance Commercial |
$19,112.00
|
| Rate for Payer: WEA Trust Commercial |
$2,627.90
|
| Rate for Payer: WPS Commercial |
$3,539.06
|
|
|
PLATE MATRIX WAVE MMF 10HL SHORT 04.503.820
|
Facility
|
IP
|
$4,778.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,341.22 |
| Max. Negotiated Rate |
$4,395.76 |
| Rate for Payer: Aetna Commercial |
$4,300.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,109.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,532.34
|
| Rate for Payer: Cash Price |
$1,433.40
|
| Rate for Payer: Cigna Commercial |
$4,395.76
|
| Rate for Payer: Health EOS Commercial |
$4,252.42
|
| Rate for Payer: HFN Commercial |
$4,395.76
|
| Rate for Payer: Multiplan Commercial |
$3,822.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,866.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,395.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,341.22
|
| Rate for Payer: Quartz Commercial |
$2,866.80
|
| Rate for Payer: WEA Trust Commercial |
$2,627.90
|
| Rate for Payer: WPS Commercial |
$3,539.06
|
|
|
PLATE MEDIAL DISTAL HUMERUS
|
Facility
|
OP
|
$6,961.00
|
|
| Hospital Charge Code |
2966372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,949.08 |
| Max. Negotiated Rate |
$27,844.00 |
| Rate for Payer: Aetna Commercial |
$6,264.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,986.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,949.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,524.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,480.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,341.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,689.33
|
| Rate for Payer: Cash Price |
$2,088.30
|
| Rate for Payer: Cigna Commercial |
$6,404.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,895.38
|
| Rate for Payer: Health EOS Commercial |
$6,195.29
|
| Rate for Payer: HFN Commercial |
$6,404.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,220.75
|
| Rate for Payer: Multiplan Commercial |
$5,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,176.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,404.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,410.89
|
| Rate for Payer: Quartz Commercial |
$4,524.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,176.60
|
| Rate for Payer: The Alliance Commercial |
$27,844.00
|
| Rate for Payer: WEA Trust Commercial |
$3,828.55
|
| Rate for Payer: WPS Commercial |
$5,156.01
|
|
|
PLATE MEDIAL DISTAL HUMERUS
|
Facility
|
IP
|
$6,961.00
|
|
| Hospital Charge Code |
2966372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,410.89 |
| Max. Negotiated Rate |
$6,404.12 |
| Rate for Payer: Aetna Commercial |
$6,264.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,986.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,689.33
|
| Rate for Payer: Cash Price |
$2,088.30
|
| Rate for Payer: Cigna Commercial |
$6,404.12
|
| Rate for Payer: Health EOS Commercial |
$6,195.29
|
| Rate for Payer: HFN Commercial |
$6,404.12
|
| Rate for Payer: Multiplan Commercial |
$5,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,176.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,404.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,410.89
|
| Rate for Payer: Quartz Commercial |
$4,176.60
|
| Rate for Payer: WEA Trust Commercial |
$3,828.55
|
| Rate for Payer: WPS Commercial |
$5,156.01
|
|
|
PLATE MEDIAL TIBIA LT MD ORTHOLOC 3DI PLATING SYSTEM 5888802L
|
Facility
|
IP
|
$11,022.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,400.78 |
| Max. Negotiated Rate |
$10,140.24 |
| Rate for Payer: Aetna Commercial |
$9,919.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,478.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,841.66
|
| Rate for Payer: Cash Price |
$3,306.60
|
| Rate for Payer: Cigna Commercial |
$10,140.24
|
| Rate for Payer: Health EOS Commercial |
$9,809.58
|
| Rate for Payer: HFN Commercial |
$10,140.24
|
| Rate for Payer: Multiplan Commercial |
$8,817.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,613.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,140.24
|
| Rate for Payer: Quartz Beloit One Network |
$5,400.78
|
| Rate for Payer: Quartz Commercial |
$6,613.20
|
| Rate for Payer: WEA Trust Commercial |
$6,062.10
|
| Rate for Payer: WPS Commercial |
$8,164.00
|
|
|
PLATE MEDIAL TIBIA LT MD ORTHOLOC 3DI PLATING SYSTEM 5888802L
|
Facility
|
OP
|
$11,022.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,086.16 |
| Max. Negotiated Rate |
$44,088.00 |
| Rate for Payer: Aetna Commercial |
$9,919.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,478.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,086.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,164.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,511.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,290.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,841.66
|
| Rate for Payer: Cash Price |
$3,306.60
|
| Rate for Payer: Cigna Commercial |
$10,140.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,167.91
|
| Rate for Payer: Health EOS Commercial |
$9,809.58
|
| Rate for Payer: HFN Commercial |
$10,140.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,266.50
|
| Rate for Payer: Multiplan Commercial |
$8,817.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,613.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,140.24
|
| Rate for Payer: Quartz Beloit One Network |
$5,400.78
|
| Rate for Payer: Quartz Commercial |
$7,164.30
|
| Rate for Payer: Quartz Medicare Advantage |
$6,613.20
|
| Rate for Payer: The Alliance Commercial |
$44,088.00
|
| Rate for Payer: WEA Trust Commercial |
$6,062.10
|
| Rate for Payer: WPS Commercial |
$8,164.00
|
|
|
PLATE MESH TITANIUM 01-7340
|
Facility
|
OP
|
$5,136.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,438.08 |
| Max. Negotiated Rate |
$20,544.00 |
| Rate for Payer: Aetna Commercial |
$4,622.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,416.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,438.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,338.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,568.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,465.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,722.08
|
| Rate for Payer: Cash Price |
$1,540.80
|
| Rate for Payer: Cigna Commercial |
$4,725.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,874.11
|
| Rate for Payer: Health EOS Commercial |
$4,571.04
|
| Rate for Payer: HFN Commercial |
$4,725.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,852.00
|
| Rate for Payer: Multiplan Commercial |
$4,108.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,081.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,725.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,516.64
|
| Rate for Payer: Quartz Commercial |
$3,338.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,081.60
|
| Rate for Payer: The Alliance Commercial |
$20,544.00
|
| Rate for Payer: WEA Trust Commercial |
$2,824.80
|
| Rate for Payer: WPS Commercial |
$3,804.24
|
|
|
PLATE MESH TITANIUM 01-7340
|
Facility
|
IP
|
$5,136.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,516.64 |
| Max. Negotiated Rate |
$4,725.12 |
| Rate for Payer: Aetna Commercial |
$4,622.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,416.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,722.08
|
| Rate for Payer: Cash Price |
$1,540.80
|
| Rate for Payer: Cigna Commercial |
$4,725.12
|
| Rate for Payer: Health EOS Commercial |
$4,571.04
|
| Rate for Payer: HFN Commercial |
$4,725.12
|
| Rate for Payer: Multiplan Commercial |
$4,108.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,081.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,725.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,516.64
|
| Rate for Payer: Quartz Commercial |
$3,081.60
|
| Rate for Payer: WEA Trust Commercial |
$2,824.80
|
| Rate for Payer: WPS Commercial |
$3,804.24
|
|
|
PLATE METAPHYSEAL 4.5/3.5 12HL
|
Facility
|
OP
|
$8,115.00
|
|
| Hospital Charge Code |
2966373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,272.20 |
| Max. Negotiated Rate |
$32,460.00 |
| Rate for Payer: Aetna Commercial |
$7,303.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,978.90
|
| Rate for Payer: Aetna Managed Medicare |
$2,272.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,274.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,057.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,895.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,300.95
|
| Rate for Payer: Cash Price |
$2,434.50
|
| Rate for Payer: Cigna Commercial |
$7,465.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,541.15
|
| Rate for Payer: Health EOS Commercial |
$7,222.35
|
| Rate for Payer: HFN Commercial |
$7,465.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,086.25
|
| Rate for Payer: Multiplan Commercial |
$6,492.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,869.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,465.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,976.35
|
| Rate for Payer: Quartz Commercial |
$5,274.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,869.00
|
| Rate for Payer: The Alliance Commercial |
$32,460.00
|
| Rate for Payer: WEA Trust Commercial |
$4,463.25
|
| Rate for Payer: WPS Commercial |
$6,010.78
|
|
|
PLATE METAPHYSEAL 4.5/3.5 12HL
|
Facility
|
IP
|
$8,115.00
|
|
| Hospital Charge Code |
2966373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,976.35 |
| Max. Negotiated Rate |
$7,465.80 |
| Rate for Payer: Aetna Commercial |
$7,303.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,978.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,300.95
|
| Rate for Payer: Cash Price |
$2,434.50
|
| Rate for Payer: Cigna Commercial |
$7,465.80
|
| Rate for Payer: Health EOS Commercial |
$7,222.35
|
| Rate for Payer: HFN Commercial |
$7,465.80
|
| Rate for Payer: Multiplan Commercial |
$6,492.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,869.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,465.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,976.35
|
| Rate for Payer: Quartz Commercial |
$4,869.00
|
| Rate for Payer: WEA Trust Commercial |
$4,463.25
|
| Rate for Payer: WPS Commercial |
$6,010.78
|
|
|
PLATE MIB LT 300-70-002
|
Facility
|
IP
|
$9,494.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5456742
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,652.06 |
| Max. Negotiated Rate |
$8,734.48 |
| Rate for Payer: Aetna Commercial |
$8,544.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.82
|
| Rate for Payer: Cash Price |
$2,848.20
|
| Rate for Payer: Cigna Commercial |
$8,734.48
|
| Rate for Payer: Health EOS Commercial |
$8,449.66
|
| Rate for Payer: HFN Commercial |
$8,734.48
|
| Rate for Payer: Multiplan Commercial |
$7,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,696.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,734.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,652.06
|
| Rate for Payer: Quartz Commercial |
$5,696.40
|
| Rate for Payer: WEA Trust Commercial |
$5,221.70
|
| Rate for Payer: WPS Commercial |
$7,032.21
|
|
|
PLATE MIB LT 300-70-002
|
Facility
|
OP
|
$9,494.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5456742
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,658.32 |
| Max. Negotiated Rate |
$37,976.00 |
| Rate for Payer: Aetna Commercial |
$8,544.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,658.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,171.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,747.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,557.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.82
|
| Rate for Payer: Cash Price |
$2,848.20
|
| Rate for Payer: Cigna Commercial |
$8,734.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,312.84
|
| Rate for Payer: Health EOS Commercial |
$8,449.66
|
| Rate for Payer: HFN Commercial |
$8,734.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,120.50
|
| Rate for Payer: Multiplan Commercial |
$7,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,696.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,734.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,652.06
|
| Rate for Payer: Quartz Commercial |
$6,171.10
|
| Rate for Payer: Quartz Medicare Advantage |
$5,696.40
|
| Rate for Payer: The Alliance Commercial |
$37,976.00
|
| Rate for Payer: WEA Trust Commercial |
$5,221.70
|
| Rate for Payer: WPS Commercial |
$7,032.21
|
|
|
PLATE MIB RT 300-70-001
|
Facility
|
OP
|
$9,874.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415997
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,764.72 |
| Max. Negotiated Rate |
$39,496.00 |
| Rate for Payer: Aetna Commercial |
$8,886.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,491.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,764.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,418.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,937.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,739.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,233.22
|
| Rate for Payer: Cash Price |
$2,962.20
|
| Rate for Payer: Cigna Commercial |
$9,084.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,525.49
|
| Rate for Payer: Health EOS Commercial |
$8,787.86
|
| Rate for Payer: HFN Commercial |
$9,084.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,405.50
|
| Rate for Payer: Multiplan Commercial |
$7,899.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,924.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,084.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,838.26
|
| Rate for Payer: Quartz Commercial |
$6,418.10
|
| Rate for Payer: Quartz Medicare Advantage |
$5,924.40
|
| Rate for Payer: The Alliance Commercial |
$39,496.00
|
| Rate for Payer: WEA Trust Commercial |
$5,430.70
|
| Rate for Payer: WPS Commercial |
$7,313.67
|
|
|
PLATE MIB RT 300-70-001
|
Facility
|
IP
|
$9,874.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415997
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,838.26 |
| Max. Negotiated Rate |
$9,084.08 |
| Rate for Payer: Aetna Commercial |
$8,886.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,491.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,233.22
|
| Rate for Payer: Cash Price |
$2,962.20
|
| Rate for Payer: Cigna Commercial |
$9,084.08
|
| Rate for Payer: Health EOS Commercial |
$8,787.86
|
| Rate for Payer: HFN Commercial |
$9,084.08
|
| Rate for Payer: Multiplan Commercial |
$7,899.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,924.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,084.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,838.26
|
| Rate for Payer: Quartz Commercial |
$5,924.40
|
| Rate for Payer: WEA Trust Commercial |
$5,430.70
|
| Rate for Payer: WPS Commercial |
$7,313.67
|
|
|
PLATE MINI 3HL 243.13
|
Facility
|
IP
|
$370.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$340.40 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$222.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
PLATE MINI 3HL 243.13
|
Facility
|
OP
|
$370.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$1,480.00 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Aetna Managed Medicare |
$103.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.05
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.50
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$240.50
|
| Rate for Payer: Quartz Medicare Advantage |
$222.00
|
| Rate for Payer: The Alliance Commercial |
$1,480.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
PLATE MINI 4HL 243.14
|
Facility
|
IP
|
$404.00
|
|
| Hospital Charge Code |
2975069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$197.96 |
| Max. Negotiated Rate |
$371.68 |
| Rate for Payer: Aetna Commercial |
$363.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.12
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$371.68
|
| Rate for Payer: Health EOS Commercial |
$359.56
|
| Rate for Payer: HFN Commercial |
$371.68
|
| Rate for Payer: Multiplan Commercial |
$323.20
|
| Rate for Payer: NAPHCARE Commercial |
$242.40
|
| Rate for Payer: Preferred Network Access Commercial |
$371.68
|
| Rate for Payer: Quartz Beloit One Network |
$197.96
|
| Rate for Payer: Quartz Commercial |
$242.40
|
| Rate for Payer: WEA Trust Commercial |
$222.20
|
| Rate for Payer: WPS Commercial |
$299.24
|
|
|
PLATE MINI 4HL 243.14
|
Facility
|
OP
|
$404.00
|
|
| Hospital Charge Code |
2975069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$113.12 |
| Max. Negotiated Rate |
$1,616.00 |
| Rate for Payer: Aetna Commercial |
$363.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.44
|
| Rate for Payer: Aetna Managed Medicare |
$113.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$262.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$202.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$193.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.12
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$371.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.08
|
| Rate for Payer: Health EOS Commercial |
$359.56
|
| Rate for Payer: HFN Commercial |
$371.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.00
|
| Rate for Payer: Multiplan Commercial |
$323.20
|
| Rate for Payer: NAPHCARE Commercial |
$242.40
|
| Rate for Payer: Preferred Network Access Commercial |
$371.68
|
| Rate for Payer: Quartz Beloit One Network |
$197.96
|
| Rate for Payer: Quartz Commercial |
$262.60
|
| Rate for Payer: Quartz Medicare Advantage |
$242.40
|
| Rate for Payer: The Alliance Commercial |
$1,616.00
|
| Rate for Payer: WEA Trust Commercial |
$222.20
|
| Rate for Payer: WPS Commercial |
$299.24
|
|
|
PLATE MINI 5HL 243.15
|
Facility
|
OP
|
$161.00
|
|
| Hospital Charge Code |
2966762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$644.00 |
| Rate for Payer: Aetna Commercial |
$144.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$138.46
|
| Rate for Payer: Aetna Managed Medicare |
$45.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.33
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cigna Commercial |
$148.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.10
|
| Rate for Payer: Health EOS Commercial |
$143.29
|
| Rate for Payer: HFN Commercial |
$148.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.75
|
| Rate for Payer: Multiplan Commercial |
$128.80
|
| Rate for Payer: NAPHCARE Commercial |
$96.60
|
| Rate for Payer: Preferred Network Access Commercial |
$148.12
|
| Rate for Payer: Quartz Beloit One Network |
$78.89
|
| Rate for Payer: Quartz Commercial |
$104.65
|
| Rate for Payer: Quartz Medicare Advantage |
$96.60
|
| Rate for Payer: The Alliance Commercial |
$644.00
|
| Rate for Payer: WEA Trust Commercial |
$88.55
|
| Rate for Payer: WPS Commercial |
$119.25
|
|
|
PLATE MINI 5HL 243.15
|
Facility
|
IP
|
$161.00
|
|
| Hospital Charge Code |
2966762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$78.89 |
| Max. Negotiated Rate |
$148.12 |
| Rate for Payer: Aetna Commercial |
$144.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$138.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.33
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cigna Commercial |
$148.12
|
| Rate for Payer: Health EOS Commercial |
$143.29
|
| Rate for Payer: HFN Commercial |
$148.12
|
| Rate for Payer: Multiplan Commercial |
$128.80
|
| Rate for Payer: NAPHCARE Commercial |
$96.60
|
| Rate for Payer: Preferred Network Access Commercial |
$148.12
|
| Rate for Payer: Quartz Beloit One Network |
$78.89
|
| Rate for Payer: Quartz Commercial |
$96.60
|
| Rate for Payer: WEA Trust Commercial |
$88.55
|
| Rate for Payer: WPS Commercial |
$119.25
|
|
|
PLATE MINI LT 242.33
|
Facility
|
IP
|
$402.00
|
|
| Hospital Charge Code |
2966763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$196.98 |
| Max. Negotiated Rate |
$369.84 |
| Rate for Payer: Aetna Commercial |
$361.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$345.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.06
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$369.84
|
| Rate for Payer: Health EOS Commercial |
$357.78
|
| Rate for Payer: HFN Commercial |
$369.84
|
| Rate for Payer: Multiplan Commercial |
$321.60
|
| Rate for Payer: NAPHCARE Commercial |
$241.20
|
| Rate for Payer: Preferred Network Access Commercial |
$369.84
|
| Rate for Payer: Quartz Beloit One Network |
$196.98
|
| Rate for Payer: Quartz Commercial |
$241.20
|
| Rate for Payer: WEA Trust Commercial |
$221.10
|
| Rate for Payer: WPS Commercial |
$297.76
|
|
|
PLATE MINI LT 242.33
|
Facility
|
OP
|
$402.00
|
|
| Hospital Charge Code |
2966763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$112.56 |
| Max. Negotiated Rate |
$1,608.00 |
| Rate for Payer: Aetna Commercial |
$361.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$345.72
|
| Rate for Payer: Aetna Managed Medicare |
$112.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$261.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$201.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$192.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.06
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$369.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$224.96
|
| Rate for Payer: Health EOS Commercial |
$357.78
|
| Rate for Payer: HFN Commercial |
$369.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$301.50
|
| Rate for Payer: Multiplan Commercial |
$321.60
|
| Rate for Payer: NAPHCARE Commercial |
$241.20
|
| Rate for Payer: Preferred Network Access Commercial |
$369.84
|
| Rate for Payer: Quartz Beloit One Network |
$196.98
|
| Rate for Payer: Quartz Commercial |
$261.30
|
| Rate for Payer: Quartz Medicare Advantage |
$241.20
|
| Rate for Payer: The Alliance Commercial |
$1,608.00
|
| Rate for Payer: WEA Trust Commercial |
$221.10
|
| Rate for Payer: WPS Commercial |
$297.76
|
|
|
PLATE MINI RT 242.34
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5599596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$225.89 |
| Max. Negotiated Rate |
$424.12 |
| Rate for Payer: Aetna Commercial |
$414.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.33
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$424.12
|
| Rate for Payer: Health EOS Commercial |
$410.29
|
| Rate for Payer: HFN Commercial |
$424.12
|
| Rate for Payer: Multiplan Commercial |
$368.80
|
| Rate for Payer: NAPHCARE Commercial |
$276.60
|
| Rate for Payer: Preferred Network Access Commercial |
$424.12
|
| Rate for Payer: Quartz Beloit One Network |
$225.89
|
| Rate for Payer: Quartz Commercial |
$276.60
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
