|
PLATE MINI RT 242.34
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5599596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$129.08 |
| Max. Negotiated Rate |
$1,844.00 |
| Rate for Payer: Aetna Commercial |
$414.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Aetna Managed Medicare |
$129.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$299.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$230.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$221.28
|
| 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: Dean Health DHI/DHP/ASO |
$257.98
|
| Rate for Payer: Health EOS Commercial |
$410.29
|
| Rate for Payer: HFN Commercial |
$424.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$345.75
|
| 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 |
$299.65
|
| Rate for Payer: Quartz Medicare Advantage |
$276.60
|
| Rate for Payer: The Alliance Commercial |
$1,844.00
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
|
PLATE MTP LEFT ORTHOLOC 3Di CROSSCHECK 5820MPX1L
|
Facility
|
OP
|
$13,390.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6099635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,749.20 |
| Max. Negotiated Rate |
$53,560.00 |
| Rate for Payer: Aetna Commercial |
$12,051.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,515.40
|
| Rate for Payer: Aetna Managed Medicare |
$3,749.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,703.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,695.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,427.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,096.70
|
| Rate for Payer: Cash Price |
$4,017.00
|
| Rate for Payer: Cigna Commercial |
$12,318.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,493.04
|
| Rate for Payer: Health EOS Commercial |
$11,917.10
|
| Rate for Payer: HFN Commercial |
$12,318.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,042.50
|
| Rate for Payer: Multiplan Commercial |
$10,712.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,034.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,318.80
|
| Rate for Payer: Quartz Beloit One Network |
$6,561.10
|
| Rate for Payer: Quartz Commercial |
$8,703.50
|
| Rate for Payer: Quartz Medicare Advantage |
$8,034.00
|
| Rate for Payer: The Alliance Commercial |
$53,560.00
|
| Rate for Payer: WEA Trust Commercial |
$7,364.50
|
| Rate for Payer: WPS Commercial |
$9,917.97
|
|
|
PLATE MTP LEFT ORTHOLOC 3Di CROSSCHECK 5820MPX1L
|
Facility
|
IP
|
$13,390.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6099635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,561.10 |
| Max. Negotiated Rate |
$12,318.80 |
| Rate for Payer: Aetna Commercial |
$12,051.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,515.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,096.70
|
| Rate for Payer: Cash Price |
$4,017.00
|
| Rate for Payer: Cigna Commercial |
$12,318.80
|
| Rate for Payer: Health EOS Commercial |
$11,917.10
|
| Rate for Payer: HFN Commercial |
$12,318.80
|
| Rate for Payer: Multiplan Commercial |
$10,712.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,034.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,318.80
|
| Rate for Payer: Quartz Beloit One Network |
$6,561.10
|
| Rate for Payer: Quartz Commercial |
$8,034.00
|
| Rate for Payer: WEA Trust Commercial |
$7,364.50
|
| Rate for Payer: WPS Commercial |
$9,917.97
|
|
|
PLATE MTP LO-PRO CONTOURED TI SHORT RT AR-8944CR-P
|
Facility
|
IP
|
$7,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.09 |
| Max. Negotiated Rate |
$6,569.72 |
| Rate for Payer: Aetna Commercial |
$6,426.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,141.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,784.73
|
| Rate for Payer: Cash Price |
$2,142.30
|
| Rate for Payer: Cigna Commercial |
$6,569.72
|
| Rate for Payer: Health EOS Commercial |
$6,355.49
|
| Rate for Payer: HFN Commercial |
$6,569.72
|
| Rate for Payer: Multiplan Commercial |
$5,712.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,284.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,569.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,499.09
|
| Rate for Payer: Quartz Commercial |
$4,284.60
|
| Rate for Payer: WEA Trust Commercial |
$3,927.55
|
| Rate for Payer: WPS Commercial |
$5,289.34
|
|
|
PLATE MTP LO-PRO CONTOURED TI SHORT RT AR-8944CR-P
|
Facility
|
OP
|
$7,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,999.48 |
| Max. Negotiated Rate |
$28,564.00 |
| Rate for Payer: Aetna Commercial |
$6,426.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,141.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,999.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,641.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,570.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,427.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,784.73
|
| Rate for Payer: Cash Price |
$2,142.30
|
| Rate for Payer: Cigna Commercial |
$6,569.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,996.10
|
| Rate for Payer: Health EOS Commercial |
$6,355.49
|
| Rate for Payer: HFN Commercial |
$6,569.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,355.75
|
| Rate for Payer: Multiplan Commercial |
$5,712.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,284.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,569.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,499.09
|
| Rate for Payer: Quartz Commercial |
$4,641.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,284.60
|
| Rate for Payer: The Alliance Commercial |
$28,564.00
|
| Rate for Payer: WEA Trust Commercial |
$3,927.55
|
| Rate for Payer: WPS Commercial |
$5,289.34
|
|
|
PLATE MTP LO-PRO CONTOURED TI STD LT AR-8944CL-S
|
Facility
|
IP
|
$7,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5603770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.09 |
| Max. Negotiated Rate |
$6,569.72 |
| Rate for Payer: Aetna Commercial |
$6,426.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,141.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,784.73
|
| Rate for Payer: Cash Price |
$2,142.30
|
| Rate for Payer: Cigna Commercial |
$6,569.72
|
| Rate for Payer: Health EOS Commercial |
$6,355.49
|
| Rate for Payer: HFN Commercial |
$6,569.72
|
| Rate for Payer: Multiplan Commercial |
$5,712.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,284.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,569.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,499.09
|
| Rate for Payer: Quartz Commercial |
$4,284.60
|
| Rate for Payer: WEA Trust Commercial |
$3,927.55
|
| Rate for Payer: WPS Commercial |
$5,289.34
|
|
|
PLATE MTP LO-PRO CONTOURED TI STD LT AR-8944CL-S
|
Facility
|
OP
|
$7,141.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5603770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,999.48 |
| Max. Negotiated Rate |
$28,564.00 |
| Rate for Payer: Aetna Commercial |
$6,426.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,141.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,999.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,641.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,570.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,427.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,784.73
|
| Rate for Payer: Cash Price |
$2,142.30
|
| Rate for Payer: Cigna Commercial |
$6,569.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,996.10
|
| Rate for Payer: Health EOS Commercial |
$6,355.49
|
| Rate for Payer: HFN Commercial |
$6,569.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,355.75
|
| Rate for Payer: Multiplan Commercial |
$5,712.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,284.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,569.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,499.09
|
| Rate for Payer: Quartz Commercial |
$4,641.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,284.60
|
| Rate for Payer: The Alliance Commercial |
$28,564.00
|
| Rate for Payer: WEA Trust Commercial |
$3,927.55
|
| Rate for Payer: WPS Commercial |
$5,289.34
|
|
|
PLATE MTP RIGHT ORTHOLOC 3Di CROSSCHECK 5820MPX1R
|
Facility
|
OP
|
$14,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458985
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,971.52 |
| Max. Negotiated Rate |
$56,736.00 |
| Rate for Payer: Aetna Commercial |
$12,765.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,198.24
|
| Rate for Payer: Aetna Managed Medicare |
$3,971.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,219.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,092.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,808.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,517.52
|
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Cigna Commercial |
$13,049.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,937.37
|
| Rate for Payer: Health EOS Commercial |
$12,623.76
|
| Rate for Payer: HFN Commercial |
$13,049.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,638.00
|
| Rate for Payer: Multiplan Commercial |
$11,347.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,510.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,049.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,950.16
|
| Rate for Payer: Quartz Commercial |
$9,219.60
|
| Rate for Payer: Quartz Medicare Advantage |
$8,510.40
|
| Rate for Payer: The Alliance Commercial |
$56,736.00
|
| Rate for Payer: WEA Trust Commercial |
$7,801.20
|
| Rate for Payer: WPS Commercial |
$10,506.09
|
|
|
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 |
$6,950.16 |
| Max. Negotiated Rate |
$13,049.28 |
| Rate for Payer: Aetna Commercial |
$12,765.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,198.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,517.52
|
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Cigna Commercial |
$13,049.28
|
| Rate for Payer: Health EOS Commercial |
$12,623.76
|
| Rate for Payer: HFN Commercial |
$13,049.28
|
| Rate for Payer: Multiplan Commercial |
$11,347.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,510.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,049.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,950.16
|
| Rate for Payer: Quartz Commercial |
$8,510.40
|
| Rate for Payer: WEA Trust Commercial |
$7,801.20
|
| Rate for Payer: WPS Commercial |
$10,506.09
|
|
|
PLATE NARROW LCP 10HL 224.601
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 10HL 224.601
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 12HL 224.621
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 12HL 224.621
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 4HL 224.541
|
Facility
|
OP
|
$5,040.00
|
|
| Hospital Charge Code |
2966766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.20 |
| Max. Negotiated Rate |
$20,160.00 |
| Rate for Payer: Aetna Commercial |
$4,536.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,334.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.20
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna Commercial |
$4,636.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.38
|
| Rate for Payer: Health EOS Commercial |
$4,485.60
|
| Rate for Payer: HFN Commercial |
$4,636.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.00
|
| Rate for Payer: Multiplan Commercial |
$4,032.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,636.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.60
|
| Rate for Payer: Quartz Commercial |
$3,276.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.00
|
| Rate for Payer: The Alliance Commercial |
$20,160.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.00
|
| Rate for Payer: WPS Commercial |
$3,733.13
|
|
|
PLATE NARROW LCP 4HL 224.541
|
Facility
|
IP
|
$5,040.00
|
|
| Hospital Charge Code |
2966766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,469.60 |
| Max. Negotiated Rate |
$4,636.80 |
| Rate for Payer: Aetna Commercial |
$4,536.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,334.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.20
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cigna Commercial |
$4,636.80
|
| Rate for Payer: Health EOS Commercial |
$4,485.60
|
| Rate for Payer: HFN Commercial |
$4,636.80
|
| Rate for Payer: Multiplan Commercial |
$4,032.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,636.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.60
|
| Rate for Payer: Quartz Commercial |
$3,024.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.00
|
| Rate for Payer: WPS Commercial |
$3,733.13
|
|
|
PLATE NARROW LCP 5HL 224.551
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 5HL 224.551
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 6HL 224.561
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 6HL 224.561
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 7HL 224.571
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 7HL 224.571
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 8HL 224.581
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 8HL 224.581
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 9HL 224.591
|
Facility
|
IP
|
$5,041.00
|
|
| Hospital Charge Code |
2966771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,470.09 |
| Max. Negotiated Rate |
$4,637.72 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,024.60
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
|
PLATE NARROW LCP 9HL 224.591
|
Facility
|
OP
|
$5,041.00
|
|
| Hospital Charge Code |
2966771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.48 |
| Max. Negotiated Rate |
$20,164.00 |
| Rate for Payer: Aetna Commercial |
$4,536.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,335.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,411.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,276.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,520.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,671.73
|
| Rate for Payer: Cash Price |
$1,512.30
|
| Rate for Payer: Cigna Commercial |
$4,637.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,820.94
|
| Rate for Payer: Health EOS Commercial |
$4,486.49
|
| Rate for Payer: HFN Commercial |
$4,637.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,780.75
|
| Rate for Payer: Multiplan Commercial |
$4,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,024.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,637.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,470.09
|
| Rate for Payer: Quartz Commercial |
$3,276.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,024.60
|
| Rate for Payer: The Alliance Commercial |
$20,164.00
|
| Rate for Payer: WEA Trust Commercial |
$2,772.55
|
| Rate for Payer: WPS Commercial |
$3,733.87
|
|
