|
FEMORAL COMP F RT LPS FLEX GSF 00-5764-016-52
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967703
|
|
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 G-LT LPS FLEX 5960-17-51
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967692
|
|
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 G-LT LPS FLEX 5960-17-51
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967692
|
|
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 G LT LPS FLEX GSF 00-5764-017-51
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967693
|
|
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 G LT LPS FLEX GSF 00-5764-017-51
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967693
|
|
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 G-RT LPS FLEX 5960-17-52
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967694
|
|
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 G-RT LPS FLEX 5960-17-52
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967694
|
|
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 G RT LPS FLEX GSF 00-5764-017-52
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967704
|
|
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 G RT LPS FLEX GSF 00-5764-017-52
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967704
|
|
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 H LEFT LPS MACRO 5596-18-51
|
Facility
|
IP
|
$11,398.00
|
|
| Hospital Charge Code |
2967468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,808.42 |
| Max. Negotiated Rate |
$10,905.61 |
| Rate for Payer: Aetna Commercial |
$10,668.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,194.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,282.58
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,905.61
|
| Rate for Payer: Health EOS Commercial |
$10,549.99
|
| Rate for Payer: HFN Commercial |
$10,905.61
|
| Rate for Payer: Multiplan Commercial |
$9,483.14
|
| Rate for Payer: Preferred Network Access Commercial |
$10,905.61
|
| Rate for Payer: Quartz Beloit One Network |
$5,808.42
|
| Rate for Payer: Quartz Commercial |
$7,112.35
|
| Rate for Payer: WEA Trust Commercial |
$6,519.66
|
| Rate for Payer: WPS Commercial |
$8,779.88
|
|
|
FEMORAL COMP H LEFT LPS MACRO 5596-18-51
|
Facility
|
OP
|
$11,398.00
|
|
| Hospital Charge Code |
2967468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,319.10 |
| Max. Negotiated Rate |
$10,905.61 |
| Rate for Payer: Aetna Commercial |
$10,668.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,194.37
|
| Rate for Payer: Aetna Managed Medicare |
$3,319.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,705.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,926.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,689.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,282.58
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,905.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,633.64
|
| Rate for Payer: Health EOS Commercial |
$10,549.99
|
| Rate for Payer: HFN Commercial |
$10,905.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,890.44
|
| Rate for Payer: Multiplan Commercial |
$9,483.14
|
| Rate for Payer: NAPHCARE Commercial |
$7,112.35
|
| Rate for Payer: Preferred Network Access Commercial |
$10,905.61
|
| Rate for Payer: Quartz Beloit One Network |
$5,808.42
|
| Rate for Payer: Quartz Commercial |
$7,705.05
|
| Rate for Payer: Quartz Medicare Advantage |
$7,112.35
|
| Rate for Payer: The Alliance Commercial |
$5,926.96
|
| Rate for Payer: WEA Trust Commercial |
$6,519.66
|
| Rate for Payer: WPS Commercial |
$8,779.88
|
|
|
FEMORAL COMP H RIGHT LPS MACRO 5596-18-52
|
Facility
|
IP
|
$11,398.00
|
|
| Hospital Charge Code |
2967469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,808.42 |
| Max. Negotiated Rate |
$10,905.61 |
| Rate for Payer: Aetna Commercial |
$10,668.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,194.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,282.58
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,905.61
|
| Rate for Payer: Health EOS Commercial |
$10,549.99
|
| Rate for Payer: HFN Commercial |
$10,905.61
|
| Rate for Payer: Multiplan Commercial |
$9,483.14
|
| Rate for Payer: Preferred Network Access Commercial |
$10,905.61
|
| Rate for Payer: Quartz Beloit One Network |
$5,808.42
|
| Rate for Payer: Quartz Commercial |
$7,112.35
|
| Rate for Payer: WEA Trust Commercial |
$6,519.66
|
| Rate for Payer: WPS Commercial |
$8,779.88
|
|
|
FEMORAL COMP H RIGHT LPS MACRO 5596-18-52
|
Facility
|
OP
|
$11,398.00
|
|
| Hospital Charge Code |
2967469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,319.10 |
| Max. Negotiated Rate |
$10,905.61 |
| Rate for Payer: Aetna Commercial |
$10,668.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,194.37
|
| Rate for Payer: Aetna Managed Medicare |
$3,319.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,705.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,926.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,689.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,282.58
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,905.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,633.64
|
| Rate for Payer: Health EOS Commercial |
$10,549.99
|
| Rate for Payer: HFN Commercial |
$10,905.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,890.44
|
| Rate for Payer: Multiplan Commercial |
$9,483.14
|
| Rate for Payer: NAPHCARE Commercial |
$7,112.35
|
| Rate for Payer: Preferred Network Access Commercial |
$10,905.61
|
| Rate for Payer: Quartz Beloit One Network |
$5,808.42
|
| Rate for Payer: Quartz Commercial |
$7,705.05
|
| Rate for Payer: Quartz Medicare Advantage |
$7,112.35
|
| Rate for Payer: The Alliance Commercial |
$5,926.96
|
| Rate for Payer: WEA Trust Commercial |
$6,519.66
|
| Rate for Payer: WPS Commercial |
$8,779.88
|
|
|
FEMORAL COMPONENT 3 LT OXINIUM 7141213
|
Facility
|
IP
|
$34,168.00
|
|
| Hospital Charge Code |
2966011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17,412.01 |
| Max. Negotiated Rate |
$32,691.94 |
| Rate for Payer: Aetna Commercial |
$31,981.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,559.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,833.40
|
| Rate for Payer: Cash Price |
$10,250.40
|
| Rate for Payer: Cigna Commercial |
$32,691.94
|
| Rate for Payer: Health EOS Commercial |
$31,625.90
|
| Rate for Payer: HFN Commercial |
$32,691.94
|
| Rate for Payer: Multiplan Commercial |
$28,427.78
|
| Rate for Payer: Preferred Network Access Commercial |
$32,691.94
|
| Rate for Payer: Quartz Beloit One Network |
$17,412.01
|
| Rate for Payer: Quartz Commercial |
$21,320.83
|
| Rate for Payer: WEA Trust Commercial |
$19,544.10
|
| Rate for Payer: WPS Commercial |
$26,319.61
|
|
|
FEMORAL COMPONENT 3 LT OXINIUM 7141213
|
Facility
|
OP
|
$34,168.00
|
|
| Hospital Charge Code |
2966011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,949.72 |
| Max. Negotiated Rate |
$32,691.94 |
| Rate for Payer: Aetna Commercial |
$31,981.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,559.86
|
| Rate for Payer: Aetna Managed Medicare |
$9,949.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,097.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,767.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,056.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,833.40
|
| Rate for Payer: Cash Price |
$10,250.40
|
| Rate for Payer: Cigna Commercial |
$32,691.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,885.78
|
| Rate for Payer: Health EOS Commercial |
$31,625.90
|
| Rate for Payer: HFN Commercial |
$32,691.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,651.04
|
| Rate for Payer: Multiplan Commercial |
$28,427.78
|
| Rate for Payer: NAPHCARE Commercial |
$21,320.83
|
| Rate for Payer: Preferred Network Access Commercial |
$32,691.94
|
| Rate for Payer: Quartz Beloit One Network |
$17,412.01
|
| Rate for Payer: Quartz Commercial |
$23,097.57
|
| Rate for Payer: Quartz Medicare Advantage |
$21,320.83
|
| Rate for Payer: The Alliance Commercial |
$17,767.36
|
| Rate for Payer: WEA Trust Commercial |
$19,544.10
|
| Rate for Payer: WPS Commercial |
$26,319.61
|
|
|
FEMORAL COMPONENT 6.0x2.0x1.0
|
Facility
|
IP
|
$12,202.00
|
|
| Hospital Charge Code |
2964728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
FEMORAL COMPONENT 6.0x2.0x1.0
|
Facility
|
OP
|
$12,202.00
|
|
| Hospital Charge Code |
2964728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
FEMORAL COMPONENT AS VEGA F5N RT NARROW NX031Z
|
Facility
|
IP
|
$8,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,385.62 |
| Max. Negotiated Rate |
$8,234.22 |
| Rate for Payer: Aetna Commercial |
$8,055.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,697.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,743.63
|
| Rate for Payer: Cash Price |
$2,581.80
|
| Rate for Payer: Cigna Commercial |
$8,234.22
|
| Rate for Payer: Health EOS Commercial |
$7,965.71
|
| Rate for Payer: HFN Commercial |
$8,234.22
|
| Rate for Payer: Multiplan Commercial |
$7,160.19
|
| Rate for Payer: Preferred Network Access Commercial |
$8,234.22
|
| Rate for Payer: Quartz Beloit One Network |
$4,385.62
|
| Rate for Payer: Quartz Commercial |
$5,370.14
|
| Rate for Payer: WEA Trust Commercial |
$4,922.63
|
| Rate for Payer: WPS Commercial |
$6,629.20
|
|
|
FEMORAL COMPONENT AS VEGA F5N RT NARROW NX031Z
|
Facility
|
OP
|
$8,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,506.07 |
| Max. Negotiated Rate |
$8,234.22 |
| Rate for Payer: Aetna Commercial |
$8,055.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,697.21
|
| Rate for Payer: Aetna Managed Medicare |
$2,506.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,817.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,475.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,296.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,743.63
|
| Rate for Payer: Cash Price |
$2,581.80
|
| Rate for Payer: Cigna Commercial |
$8,234.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,008.69
|
| Rate for Payer: Health EOS Commercial |
$7,965.71
|
| Rate for Payer: HFN Commercial |
$8,234.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,712.68
|
| Rate for Payer: Multiplan Commercial |
$7,160.19
|
| Rate for Payer: NAPHCARE Commercial |
$5,370.14
|
| Rate for Payer: Preferred Network Access Commercial |
$8,234.22
|
| Rate for Payer: Quartz Beloit One Network |
$4,385.62
|
| Rate for Payer: Quartz Commercial |
$5,817.66
|
| Rate for Payer: Quartz Medicare Advantage |
$5,370.14
|
| Rate for Payer: The Alliance Commercial |
$4,475.12
|
| Rate for Payer: WEA Trust Commercial |
$4,922.63
|
| Rate for Payer: WPS Commercial |
$6,629.20
|
|
|
FEMORAL COMPONENT C-LT LPS FLEX 5960-13-51
|
Facility
|
IP
|
$18,598.00
|
|
| Hospital Charge Code |
3259461
|
|
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 COMPONENT C-LT LPS FLEX 5960-13-51
|
Facility
|
OP
|
$18,598.00
|
|
| Hospital Charge Code |
3259461
|
|
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 COMPONENT D LEFT
|
Facility
|
OP
|
$22,690.00
|
|
| Hospital Charge Code |
2967470
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,607.33 |
| Max. Negotiated Rate |
$21,709.79 |
| Rate for Payer: Aetna Commercial |
$21,237.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,293.94
|
| Rate for Payer: Aetna Managed Medicare |
$6,607.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,338.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,798.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,326.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,506.73
|
| Rate for Payer: Cash Price |
$6,807.00
|
| Rate for Payer: Cigna Commercial |
$21,709.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,205.58
|
| Rate for Payer: Health EOS Commercial |
$21,001.86
|
| Rate for Payer: HFN Commercial |
$21,709.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,698.20
|
| Rate for Payer: Multiplan Commercial |
$18,878.08
|
| Rate for Payer: NAPHCARE Commercial |
$14,158.56
|
| Rate for Payer: Preferred Network Access Commercial |
$21,709.79
|
| Rate for Payer: Quartz Beloit One Network |
$11,562.82
|
| Rate for Payer: Quartz Commercial |
$15,338.44
|
| Rate for Payer: Quartz Medicare Advantage |
$14,158.56
|
| Rate for Payer: The Alliance Commercial |
$11,798.80
|
| Rate for Payer: WEA Trust Commercial |
$12,978.68
|
| Rate for Payer: WPS Commercial |
$17,478.11
|
|
|
FEMORAL COMPONENT D LEFT
|
Facility
|
IP
|
$22,690.00
|
|
| Hospital Charge Code |
2967470
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,562.82 |
| Max. Negotiated Rate |
$21,709.79 |
| Rate for Payer: Aetna Commercial |
$21,237.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,293.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,506.73
|
| Rate for Payer: Cash Price |
$6,807.00
|
| Rate for Payer: Cigna Commercial |
$21,709.79
|
| Rate for Payer: Health EOS Commercial |
$21,001.86
|
| Rate for Payer: HFN Commercial |
$21,709.79
|
| Rate for Payer: Multiplan Commercial |
$18,878.08
|
| Rate for Payer: Preferred Network Access Commercial |
$21,709.79
|
| Rate for Payer: Quartz Beloit One Network |
$11,562.82
|
| Rate for Payer: Quartz Commercial |
$14,158.56
|
| Rate for Payer: WEA Trust Commercial |
$12,978.68
|
| Rate for Payer: WPS Commercial |
$17,478.11
|
|
|
FEMORAL COMPONENT F RT W/TI-
|
Facility
|
IP
|
$21,849.00
|
|
| Hospital Charge Code |
2967472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,134.25 |
| Max. Negotiated Rate |
$20,905.12 |
| Rate for Payer: Aetna Commercial |
$20,450.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,541.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,043.17
|
| Rate for Payer: Cash Price |
$6,554.70
|
| Rate for Payer: Cigna Commercial |
$20,905.12
|
| Rate for Payer: Health EOS Commercial |
$20,223.43
|
| Rate for Payer: HFN Commercial |
$20,905.12
|
| Rate for Payer: Multiplan Commercial |
$18,178.37
|
| Rate for Payer: Preferred Network Access Commercial |
$20,905.12
|
| Rate for Payer: Quartz Beloit One Network |
$11,134.25
|
| Rate for Payer: Quartz Commercial |
$13,633.78
|
| Rate for Payer: WEA Trust Commercial |
$12,497.63
|
| Rate for Payer: WPS Commercial |
$16,830.28
|
|
|
FEMORAL COMPONENT F RT W/TI-
|
Facility
|
OP
|
$21,849.00
|
|
| Hospital Charge Code |
2967472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,362.43 |
| Max. Negotiated Rate |
$20,905.12 |
| Rate for Payer: Aetna Commercial |
$20,450.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,541.75
|
| Rate for Payer: Aetna Managed Medicare |
$6,362.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,769.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,361.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,907.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,043.17
|
| Rate for Payer: Cash Price |
$6,554.70
|
| Rate for Payer: Cigna Commercial |
$20,905.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,716.12
|
| Rate for Payer: Health EOS Commercial |
$20,223.43
|
| Rate for Payer: HFN Commercial |
$20,905.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,042.22
|
| Rate for Payer: Multiplan Commercial |
$18,178.37
|
| Rate for Payer: NAPHCARE Commercial |
$13,633.78
|
| Rate for Payer: Preferred Network Access Commercial |
$20,905.12
|
| Rate for Payer: Quartz Beloit One Network |
$11,134.25
|
| Rate for Payer: Quartz Commercial |
$14,769.92
|
| Rate for Payer: Quartz Medicare Advantage |
$13,633.78
|
| Rate for Payer: The Alliance Commercial |
$11,361.48
|
| Rate for Payer: WEA Trust Commercial |
$12,497.63
|
| Rate for Payer: WPS Commercial |
$16,830.28
|
|
