|
FEMORAL COMP D-LT LPS FLEX 5960-14-51
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,477.54 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$11,605.15
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP D-LT LPS FLEX 5960-14-51
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,415.74 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Aetna Managed Medicare |
$5,415.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,572.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,670.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,284.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,824.04
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,506.44
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: NAPHCARE Commercial |
$11,605.15
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$12,572.25
|
| Rate for Payer: Quartz Medicare Advantage |
$11,605.15
|
| Rate for Payer: The Alliance Commercial |
$9,670.96
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP D-LT LPS FLEX GSF 00-5764-014-51
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP D-LT LPS FLEX GSF 00-5764-014-51
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP D-RT LPS FLEX 5960-14-52
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,477.54 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$11,605.15
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP D-RT LPS FLEX 5960-14-52
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,415.74 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Aetna Managed Medicare |
$5,415.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,572.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,670.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,284.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,824.04
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,506.44
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: NAPHCARE Commercial |
$11,605.15
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$12,572.25
|
| Rate for Payer: Quartz Medicare Advantage |
$11,605.15
|
| Rate for Payer: The Alliance Commercial |
$9,670.96
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP D-RT LPS FLEX GSF 00-5764-014-52
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP D-RT LPS FLEX GSF 00-5764-014-52
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP E-LT LPS FLEX 5960-15-51
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,415.74 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Aetna Managed Medicare |
$5,415.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,572.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,670.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,284.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,824.04
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,506.44
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: NAPHCARE Commercial |
$11,605.15
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$12,572.25
|
| Rate for Payer: Quartz Medicare Advantage |
$11,605.15
|
| Rate for Payer: The Alliance Commercial |
$9,670.96
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP E-LT LPS FLEX 5960-15-51
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,477.54 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$11,605.15
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP E-LT LPS FLEX GSF 00-5764-015-51
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP E-LT LPS FLEX GSF 00-5764-015-51
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP E-RT LCCK 5994-15-92
|
Facility
|
IP
|
$31,995.00
|
|
| Hospital Charge Code |
2969424
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,304.65 |
| Max. Negotiated Rate |
$30,612.82 |
| Rate for Payer: Aetna Commercial |
$29,947.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,616.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,635.64
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$30,612.82
|
| Rate for Payer: Health EOS Commercial |
$29,614.57
|
| Rate for Payer: HFN Commercial |
$30,612.82
|
| Rate for Payer: Multiplan Commercial |
$26,619.84
|
| Rate for Payer: Preferred Network Access Commercial |
$30,612.82
|
| Rate for Payer: Quartz Beloit One Network |
$16,304.65
|
| Rate for Payer: Quartz Commercial |
$19,964.88
|
| Rate for Payer: WEA Trust Commercial |
$18,301.14
|
| Rate for Payer: WPS Commercial |
$24,645.75
|
|
|
FEMORAL COMP E-RT LCCK 5994-15-92
|
Facility
|
OP
|
$31,995.00
|
|
| Hospital Charge Code |
2969424
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,316.94 |
| Max. Negotiated Rate |
$30,612.82 |
| Rate for Payer: Aetna Commercial |
$29,947.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,616.33
|
| Rate for Payer: Aetna Managed Medicare |
$9,316.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,628.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,637.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,971.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,635.64
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$30,612.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,621.09
|
| Rate for Payer: Health EOS Commercial |
$29,614.57
|
| Rate for Payer: HFN Commercial |
$30,612.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,956.10
|
| Rate for Payer: Multiplan Commercial |
$26,619.84
|
| Rate for Payer: NAPHCARE Commercial |
$19,964.88
|
| Rate for Payer: Preferred Network Access Commercial |
$30,612.82
|
| Rate for Payer: Quartz Beloit One Network |
$16,304.65
|
| Rate for Payer: Quartz Commercial |
$21,628.62
|
| Rate for Payer: Quartz Medicare Advantage |
$19,964.88
|
| Rate for Payer: The Alliance Commercial |
$16,637.40
|
| Rate for Payer: WEA Trust Commercial |
$18,301.14
|
| Rate for Payer: WPS Commercial |
$24,645.75
|
|
|
FEMORAL COMP E-RT LPS FLEX 5960-15-52
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,415.74 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Aetna Managed Medicare |
$5,415.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,572.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,670.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,284.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,824.04
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,506.44
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: NAPHCARE Commercial |
$11,605.15
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$12,572.25
|
| Rate for Payer: Quartz Medicare Advantage |
$11,605.15
|
| Rate for Payer: The Alliance Commercial |
$9,670.96
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP E-RT LPS FLEX 5960-15-52
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,477.54 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$11,605.15
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP E-RT LPS FLEX GSF 00-5764-015-52
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP E-RT LPS FLEX GSF 00-5764-015-52
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP F-LT LPS FLEX 5960-16-51
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,415.74 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Aetna Managed Medicare |
$5,415.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,572.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,670.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,284.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,824.04
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,506.44
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: NAPHCARE Commercial |
$11,605.15
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$12,572.25
|
| Rate for Payer: Quartz Medicare Advantage |
$11,605.15
|
| Rate for Payer: The Alliance Commercial |
$9,670.96
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP F-LT LPS FLEX 5960-16-51
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,477.54 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$11,605.15
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP F-LT LPS FLEX GSF 00-5764-016-51
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967699
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP F-LT LPS FLEX GSF 00-5764-016-51
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967699
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP F-RT LPS FLEX 5960-16-52
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,415.74 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Aetna Managed Medicare |
$5,415.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,572.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,670.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,284.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,824.04
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,506.44
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: NAPHCARE Commercial |
$11,605.15
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$12,572.25
|
| Rate for Payer: Quartz Medicare Advantage |
$11,605.15
|
| Rate for Payer: The Alliance Commercial |
$9,670.96
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP F-RT LPS FLEX 5960-16-52
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,477.54 |
| Max. Negotiated Rate |
$17,794.57 |
| Rate for Payer: Aetna Commercial |
$17,407.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,634.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,251.22
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,794.57
|
| Rate for Payer: Health EOS Commercial |
$17,214.31
|
| Rate for Payer: HFN Commercial |
$17,794.57
|
| Rate for Payer: Multiplan Commercial |
$15,473.54
|
| Rate for Payer: Preferred Network Access Commercial |
$17,794.57
|
| Rate for Payer: Quartz Beloit One Network |
$9,477.54
|
| Rate for Payer: Quartz Commercial |
$11,605.15
|
| Rate for Payer: WEA Trust Commercial |
$10,638.06
|
| Rate for Payer: WPS Commercial |
$14,326.04
|
|
|
FEMORAL COMP F RT LPS FLEX GSF 00-5764-016-52
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
