|
PLATE SEMI TUBULAR 3HL 222.03
|
Facility
|
IP
|
$373.00
|
|
| Hospital Charge Code |
2966778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$182.77 |
| Max. Negotiated Rate |
$343.16 |
| Rate for Payer: Aetna Commercial |
$335.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.69
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$343.16
|
| Rate for Payer: Health EOS Commercial |
$331.97
|
| Rate for Payer: HFN Commercial |
$343.16
|
| Rate for Payer: Multiplan Commercial |
$298.40
|
| Rate for Payer: NAPHCARE Commercial |
$223.80
|
| Rate for Payer: Preferred Network Access Commercial |
$343.16
|
| Rate for Payer: Quartz Beloit One Network |
$182.77
|
| Rate for Payer: Quartz Commercial |
$223.80
|
| Rate for Payer: WEA Trust Commercial |
$205.15
|
| Rate for Payer: WPS Commercial |
$276.28
|
|
|
PLATE SEMI TUBULAR 4HL 222.04
|
Facility
|
OP
|
$405.00
|
|
| Hospital Charge Code |
2966779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Aetna Managed Medicare |
$113.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$202.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.64
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.75
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$263.25
|
| Rate for Payer: Quartz Medicare Advantage |
$243.00
|
| Rate for Payer: The Alliance Commercial |
$1,620.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
PLATE SEMI TUBULAR 4HL 222.04
|
Facility
|
IP
|
$405.00
|
|
| Hospital Charge Code |
2966779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.45 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$243.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
PLATE SEMI TUBULAR 5HL 222.05
|
Facility
|
IP
|
$422.00
|
|
| Hospital Charge Code |
2966780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.78 |
| Max. Negotiated Rate |
$388.24 |
| Rate for Payer: Aetna Commercial |
$379.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.66
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$388.24
|
| Rate for Payer: Health EOS Commercial |
$375.58
|
| Rate for Payer: HFN Commercial |
$388.24
|
| Rate for Payer: Multiplan Commercial |
$337.60
|
| Rate for Payer: NAPHCARE Commercial |
$253.20
|
| Rate for Payer: Preferred Network Access Commercial |
$388.24
|
| Rate for Payer: Quartz Beloit One Network |
$206.78
|
| Rate for Payer: Quartz Commercial |
$253.20
|
| Rate for Payer: WEA Trust Commercial |
$232.10
|
| Rate for Payer: WPS Commercial |
$312.58
|
|
|
PLATE SEMI TUBULAR 5HL 222.05
|
Facility
|
OP
|
$422.00
|
|
| Hospital Charge Code |
2966780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$118.16 |
| Max. Negotiated Rate |
$1,688.00 |
| Rate for Payer: Aetna Commercial |
$379.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.92
|
| Rate for Payer: Aetna Managed Medicare |
$118.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$274.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$211.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$202.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.66
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$388.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.15
|
| Rate for Payer: Health EOS Commercial |
$375.58
|
| Rate for Payer: HFN Commercial |
$388.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$316.50
|
| Rate for Payer: Multiplan Commercial |
$337.60
|
| Rate for Payer: NAPHCARE Commercial |
$253.20
|
| Rate for Payer: Preferred Network Access Commercial |
$388.24
|
| Rate for Payer: Quartz Beloit One Network |
$206.78
|
| Rate for Payer: Quartz Commercial |
$274.30
|
| Rate for Payer: Quartz Medicare Advantage |
$253.20
|
| Rate for Payer: The Alliance Commercial |
$1,688.00
|
| Rate for Payer: WEA Trust Commercial |
$232.10
|
| Rate for Payer: WPS Commercial |
$312.58
|
|
|
PLATE SEMI TUBULAR 6HL 222.06
|
Facility
|
IP
|
$447.00
|
|
| Hospital Charge Code |
2966781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$219.03 |
| Max. Negotiated Rate |
$411.24 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$268.20
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
PLATE SEMI TUBULAR 6HL 222.06
|
Facility
|
OP
|
$447.00
|
|
| Hospital Charge Code |
2966781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.16 |
| Max. Negotiated Rate |
$1,788.00 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Aetna Managed Medicare |
$125.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$290.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$223.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$214.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.14
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.25
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$290.55
|
| Rate for Payer: Quartz Medicare Advantage |
$268.20
|
| Rate for Payer: The Alliance Commercial |
$1,788.00
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
PLATE SEMI TUBULAR 7HL 222.07
|
Facility
|
OP
|
$478.00
|
|
| Hospital Charge Code |
2966782
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$133.84 |
| Max. Negotiated Rate |
$1,912.00 |
| Rate for Payer: Aetna Commercial |
$430.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.08
|
| Rate for Payer: Aetna Managed Medicare |
$133.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$310.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.34
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$439.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.49
|
| Rate for Payer: Health EOS Commercial |
$425.42
|
| Rate for Payer: HFN Commercial |
$439.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$358.50
|
| Rate for Payer: Multiplan Commercial |
$382.40
|
| Rate for Payer: NAPHCARE Commercial |
$286.80
|
| Rate for Payer: Preferred Network Access Commercial |
$439.76
|
| Rate for Payer: Quartz Beloit One Network |
$234.22
|
| Rate for Payer: Quartz Commercial |
$310.70
|
| Rate for Payer: Quartz Medicare Advantage |
$286.80
|
| Rate for Payer: The Alliance Commercial |
$1,912.00
|
| Rate for Payer: WEA Trust Commercial |
$262.90
|
| Rate for Payer: WPS Commercial |
$354.05
|
|
|
PLATE SEMI TUBULAR 7HL 222.07
|
Facility
|
IP
|
$478.00
|
|
| Hospital Charge Code |
2966782
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$234.22 |
| Max. Negotiated Rate |
$439.76 |
| Rate for Payer: Aetna Commercial |
$430.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.34
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$439.76
|
| Rate for Payer: Health EOS Commercial |
$425.42
|
| Rate for Payer: HFN Commercial |
$439.76
|
| Rate for Payer: Multiplan Commercial |
$382.40
|
| Rate for Payer: NAPHCARE Commercial |
$286.80
|
| Rate for Payer: Preferred Network Access Commercial |
$439.76
|
| Rate for Payer: Quartz Beloit One Network |
$234.22
|
| Rate for Payer: Quartz Commercial |
$286.80
|
| Rate for Payer: WEA Trust Commercial |
$262.90
|
| Rate for Payer: WPS Commercial |
$354.05
|
|
|
PLATE SEMI TUBULAR 8HL 222.08
|
Facility
|
IP
|
$445.00
|
|
| Hospital Charge Code |
2966783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$218.05 |
| Max. Negotiated Rate |
$409.40 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
PLATE SEMI TUBULAR 8HL 222.08
|
Facility
|
OP
|
$445.00
|
|
| Hospital Charge Code |
2966783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$124.60 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$124.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$289.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$222.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$213.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.02
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.75
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$289.25
|
| Rate for Payer: Quartz Medicare Advantage |
$267.00
|
| Rate for Payer: The Alliance Commercial |
$1,780.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
PLATE SLIM STRAIGHT 3 HOLE 626963
|
Facility
|
IP
|
$5,026.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6173720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,462.74 |
| Max. Negotiated Rate |
$4,623.92 |
| Rate for Payer: Aetna Commercial |
$4,523.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.78
|
| Rate for Payer: Cash Price |
$1,507.80
|
| Rate for Payer: Cigna Commercial |
$4,623.92
|
| Rate for Payer: Health EOS Commercial |
$4,473.14
|
| Rate for Payer: HFN Commercial |
$4,623.92
|
| Rate for Payer: Multiplan Commercial |
$4,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,015.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,623.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.74
|
| Rate for Payer: Quartz Commercial |
$3,015.60
|
| Rate for Payer: WEA Trust Commercial |
$2,764.30
|
| Rate for Payer: WPS Commercial |
$3,722.76
|
|
|
PLATE SLIM STRAIGHT 3 HOLE 626963
|
Facility
|
OP
|
$5,026.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6173720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.28 |
| Max. Negotiated Rate |
$20,104.00 |
| Rate for Payer: Aetna Commercial |
$4,523.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.36
|
| Rate for Payer: Aetna Managed Medicare |
$1,407.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,266.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,513.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,412.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.78
|
| Rate for Payer: Cash Price |
$1,507.80
|
| Rate for Payer: Cigna Commercial |
$4,623.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,812.55
|
| Rate for Payer: Health EOS Commercial |
$4,473.14
|
| Rate for Payer: HFN Commercial |
$4,623.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,769.50
|
| Rate for Payer: Multiplan Commercial |
$4,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,015.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,623.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.74
|
| Rate for Payer: Quartz Commercial |
$3,266.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,015.60
|
| Rate for Payer: The Alliance Commercial |
$20,104.00
|
| Rate for Payer: WEA Trust Commercial |
$2,764.30
|
| Rate for Payer: WPS Commercial |
$3,722.76
|
|
|
PLATE SLIM STRAIGHT 5 HOLE 626965
|
Facility
|
IP
|
$7,469.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,659.81 |
| Max. Negotiated Rate |
$6,871.48 |
| Rate for Payer: Aetna Commercial |
$6,722.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,423.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.57
|
| Rate for Payer: Cash Price |
$2,240.70
|
| Rate for Payer: Cigna Commercial |
$6,871.48
|
| Rate for Payer: Health EOS Commercial |
$6,647.41
|
| Rate for Payer: HFN Commercial |
$6,871.48
|
| Rate for Payer: Multiplan Commercial |
$5,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,481.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,871.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.81
|
| Rate for Payer: Quartz Commercial |
$4,481.40
|
| Rate for Payer: WEA Trust Commercial |
$4,107.95
|
| Rate for Payer: WPS Commercial |
$5,532.29
|
|
|
PLATE SLIM STRAIGHT 5 HOLE 626965
|
Facility
|
OP
|
$7,469.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,091.32 |
| Max. Negotiated Rate |
$29,876.00 |
| Rate for Payer: Aetna Commercial |
$6,722.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,423.34
|
| Rate for Payer: Aetna Managed Medicare |
$2,091.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,854.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,734.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,585.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.57
|
| Rate for Payer: Cash Price |
$2,240.70
|
| Rate for Payer: Cigna Commercial |
$6,871.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,179.65
|
| Rate for Payer: Health EOS Commercial |
$6,647.41
|
| Rate for Payer: HFN Commercial |
$6,871.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,601.75
|
| Rate for Payer: Multiplan Commercial |
$5,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,481.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,871.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.81
|
| Rate for Payer: Quartz Commercial |
$4,854.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,481.40
|
| Rate for Payer: The Alliance Commercial |
$29,876.00
|
| Rate for Payer: WEA Trust Commercial |
$4,107.95
|
| Rate for Payer: WPS Commercial |
$5,532.29
|
|
|
PLATE SLIM STRAIGHT 6 HOLE 626966
|
Facility
|
OP
|
$5,026.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6171787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.28 |
| Max. Negotiated Rate |
$20,104.00 |
| Rate for Payer: Aetna Commercial |
$4,523.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.36
|
| Rate for Payer: Aetna Managed Medicare |
$1,407.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,266.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,513.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,412.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.78
|
| Rate for Payer: Cash Price |
$1,507.80
|
| Rate for Payer: Cigna Commercial |
$4,623.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,812.55
|
| Rate for Payer: Health EOS Commercial |
$4,473.14
|
| Rate for Payer: HFN Commercial |
$4,623.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,769.50
|
| Rate for Payer: Multiplan Commercial |
$4,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,015.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,623.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.74
|
| Rate for Payer: Quartz Commercial |
$3,266.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,015.60
|
| Rate for Payer: The Alliance Commercial |
$20,104.00
|
| Rate for Payer: WEA Trust Commercial |
$2,764.30
|
| Rate for Payer: WPS Commercial |
$3,722.76
|
|
|
PLATE SLIM STRAIGHT 6 HOLE 626966
|
Facility
|
IP
|
$5,026.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6171787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,462.74 |
| Max. Negotiated Rate |
$4,623.92 |
| Rate for Payer: Aetna Commercial |
$4,523.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.78
|
| Rate for Payer: Cash Price |
$1,507.80
|
| Rate for Payer: Cigna Commercial |
$4,623.92
|
| Rate for Payer: Health EOS Commercial |
$4,473.14
|
| Rate for Payer: HFN Commercial |
$4,623.92
|
| Rate for Payer: Multiplan Commercial |
$4,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,015.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,623.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.74
|
| Rate for Payer: Quartz Commercial |
$3,015.60
|
| Rate for Payer: WEA Trust Commercial |
$2,764.30
|
| Rate for Payer: WPS Commercial |
$3,722.76
|
|
|
PLATE SLIM STRAIGHT 7 HOLE 626967
|
Facility
|
IP
|
$7,469.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,659.81 |
| Max. Negotiated Rate |
$6,871.48 |
| Rate for Payer: Aetna Commercial |
$6,722.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,423.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.57
|
| Rate for Payer: Cash Price |
$2,240.70
|
| Rate for Payer: Cigna Commercial |
$6,871.48
|
| Rate for Payer: Health EOS Commercial |
$6,647.41
|
| Rate for Payer: HFN Commercial |
$6,871.48
|
| Rate for Payer: Multiplan Commercial |
$5,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,481.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,871.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.81
|
| Rate for Payer: Quartz Commercial |
$4,481.40
|
| Rate for Payer: WEA Trust Commercial |
$4,107.95
|
| Rate for Payer: WPS Commercial |
$5,532.29
|
|
|
PLATE SLIM STRAIGHT 7 HOLE 626967
|
Facility
|
OP
|
$7,469.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,091.32 |
| Max. Negotiated Rate |
$29,876.00 |
| Rate for Payer: Aetna Commercial |
$6,722.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,423.34
|
| Rate for Payer: Aetna Managed Medicare |
$2,091.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,854.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,734.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,585.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.57
|
| Rate for Payer: Cash Price |
$2,240.70
|
| Rate for Payer: Cigna Commercial |
$6,871.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,179.65
|
| Rate for Payer: Health EOS Commercial |
$6,647.41
|
| Rate for Payer: HFN Commercial |
$6,871.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,601.75
|
| Rate for Payer: Multiplan Commercial |
$5,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,481.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,871.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.81
|
| Rate for Payer: Quartz Commercial |
$4,854.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,481.40
|
| Rate for Payer: The Alliance Commercial |
$29,876.00
|
| Rate for Payer: WEA Trust Commercial |
$4,107.95
|
| Rate for Payer: WPS Commercial |
$5,532.29
|
|
|
PLATE SLIM Y 2 SHAFT HOLE 626982
|
Facility
|
OP
|
$5,456.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.68 |
| Max. Negotiated Rate |
$21,824.00 |
| Rate for Payer: Aetna Commercial |
$4,910.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,692.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,527.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,546.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,728.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,618.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,891.68
|
| Rate for Payer: Cash Price |
$1,636.80
|
| Rate for Payer: Cigna Commercial |
$5,019.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,053.18
|
| Rate for Payer: Health EOS Commercial |
$4,855.84
|
| Rate for Payer: HFN Commercial |
$5,019.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,092.00
|
| Rate for Payer: Multiplan Commercial |
$4,364.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,019.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,673.44
|
| Rate for Payer: Quartz Commercial |
$3,546.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,273.60
|
| Rate for Payer: The Alliance Commercial |
$21,824.00
|
| Rate for Payer: WEA Trust Commercial |
$3,000.80
|
| Rate for Payer: WPS Commercial |
$4,041.26
|
|
|
PLATE SLIM Y 2 SHAFT HOLE 626982
|
Facility
|
IP
|
$5,456.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,673.44 |
| Max. Negotiated Rate |
$5,019.52 |
| Rate for Payer: Aetna Commercial |
$4,910.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,692.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,891.68
|
| Rate for Payer: Cash Price |
$1,636.80
|
| Rate for Payer: Cigna Commercial |
$5,019.52
|
| Rate for Payer: Health EOS Commercial |
$4,855.84
|
| Rate for Payer: HFN Commercial |
$5,019.52
|
| Rate for Payer: Multiplan Commercial |
$4,364.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,019.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,673.44
|
| Rate for Payer: Quartz Commercial |
$3,273.60
|
| Rate for Payer: WEA Trust Commercial |
$3,000.80
|
| Rate for Payer: WPS Commercial |
$4,041.26
|
|
|
PLATE SLIM Y 4 SHAFT HOLE 626984
|
Facility
|
OP
|
$5,456.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.68 |
| Max. Negotiated Rate |
$21,824.00 |
| Rate for Payer: Aetna Commercial |
$4,910.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,692.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,527.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,546.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,728.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,618.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,891.68
|
| Rate for Payer: Cash Price |
$1,636.80
|
| Rate for Payer: Cigna Commercial |
$5,019.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,053.18
|
| Rate for Payer: Health EOS Commercial |
$4,855.84
|
| Rate for Payer: HFN Commercial |
$5,019.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,092.00
|
| Rate for Payer: Multiplan Commercial |
$4,364.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,019.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,673.44
|
| Rate for Payer: Quartz Commercial |
$3,546.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,273.60
|
| Rate for Payer: The Alliance Commercial |
$21,824.00
|
| Rate for Payer: WEA Trust Commercial |
$3,000.80
|
| Rate for Payer: WPS Commercial |
$4,041.26
|
|
|
PLATE SLIM Y 4 SHAFT HOLE 626984
|
Facility
|
IP
|
$5,456.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,673.44 |
| Max. Negotiated Rate |
$5,019.52 |
| Rate for Payer: Aetna Commercial |
$4,910.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,692.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,891.68
|
| Rate for Payer: Cash Price |
$1,636.80
|
| Rate for Payer: Cigna Commercial |
$5,019.52
|
| Rate for Payer: Health EOS Commercial |
$4,855.84
|
| Rate for Payer: HFN Commercial |
$5,019.52
|
| Rate for Payer: Multiplan Commercial |
$4,364.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,019.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,673.44
|
| Rate for Payer: Quartz Commercial |
$3,273.60
|
| Rate for Payer: WEA Trust Commercial |
$3,000.80
|
| Rate for Payer: WPS Commercial |
$4,041.26
|
|
|
PLATE SPIDER 20MM SMALL 814100003
|
Facility
|
OP
|
$726.00
|
|
| Hospital Charge Code |
2965014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$203.28 |
| Max. Negotiated Rate |
$2,904.00 |
| Rate for Payer: Aetna Commercial |
$653.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$624.36
|
| Rate for Payer: Aetna Managed Medicare |
$203.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$471.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$363.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$348.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$384.78
|
| Rate for Payer: Cash Price |
$217.80
|
| Rate for Payer: Cigna Commercial |
$667.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$406.27
|
| Rate for Payer: Health EOS Commercial |
$646.14
|
| Rate for Payer: HFN Commercial |
$667.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$544.50
|
| Rate for Payer: Multiplan Commercial |
$580.80
|
| Rate for Payer: NAPHCARE Commercial |
$435.60
|
| Rate for Payer: Preferred Network Access Commercial |
$667.92
|
| Rate for Payer: Quartz Beloit One Network |
$355.74
|
| Rate for Payer: Quartz Commercial |
$471.90
|
| Rate for Payer: Quartz Medicare Advantage |
$435.60
|
| Rate for Payer: The Alliance Commercial |
$2,904.00
|
| Rate for Payer: WEA Trust Commercial |
$399.30
|
| Rate for Payer: WPS Commercial |
$537.75
|
|
|
PLATE SPIDER 20MM SMALL 814100003
|
Facility
|
IP
|
$726.00
|
|
| Hospital Charge Code |
2965014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$355.74 |
| Max. Negotiated Rate |
$667.92 |
| Rate for Payer: Aetna Commercial |
$653.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$624.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$384.78
|
| Rate for Payer: Cash Price |
$217.80
|
| Rate for Payer: Cigna Commercial |
$667.92
|
| Rate for Payer: Health EOS Commercial |
$646.14
|
| Rate for Payer: HFN Commercial |
$667.92
|
| Rate for Payer: Multiplan Commercial |
$580.80
|
| Rate for Payer: NAPHCARE Commercial |
$435.60
|
| Rate for Payer: Preferred Network Access Commercial |
$667.92
|
| Rate for Payer: Quartz Beloit One Network |
$355.74
|
| Rate for Payer: Quartz Commercial |
$435.60
|
| Rate for Payer: WEA Trust Commercial |
$399.30
|
| Rate for Payer: WPS Commercial |
$537.75
|
|
