|
FEMORAL COMPONENT OPTION SZ E
|
Facility
|
OP
|
$19,917.00
|
|
| Hospital Charge Code |
2967473
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,799.83 |
| Max. Negotiated Rate |
$19,056.59 |
| Rate for Payer: Aetna Commercial |
$18,642.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,813.76
|
| Rate for Payer: Aetna Managed Medicare |
$5,799.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,463.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,356.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,942.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,978.25
|
| Rate for Payer: Cash Price |
$5,975.10
|
| Rate for Payer: Cigna Commercial |
$19,056.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,591.69
|
| Rate for Payer: Health EOS Commercial |
$18,435.18
|
| Rate for Payer: HFN Commercial |
$19,056.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,535.26
|
| Rate for Payer: Multiplan Commercial |
$16,570.94
|
| Rate for Payer: NAPHCARE Commercial |
$12,428.21
|
| Rate for Payer: Preferred Network Access Commercial |
$19,056.59
|
| Rate for Payer: Quartz Beloit One Network |
$10,149.70
|
| Rate for Payer: Quartz Commercial |
$13,463.89
|
| Rate for Payer: Quartz Medicare Advantage |
$12,428.21
|
| Rate for Payer: The Alliance Commercial |
$10,356.84
|
| Rate for Payer: WEA Trust Commercial |
$11,392.52
|
| Rate for Payer: WPS Commercial |
$15,342.07
|
|
|
FEMORAL COMPONENT OPTION SZ E
|
Facility
|
IP
|
$19,917.00
|
|
| Hospital Charge Code |
2967473
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,149.70 |
| Max. Negotiated Rate |
$19,056.59 |
| Rate for Payer: Aetna Commercial |
$18,642.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,813.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,978.25
|
| Rate for Payer: Cash Price |
$5,975.10
|
| Rate for Payer: Cigna Commercial |
$19,056.59
|
| Rate for Payer: Health EOS Commercial |
$18,435.18
|
| Rate for Payer: HFN Commercial |
$19,056.59
|
| Rate for Payer: Multiplan Commercial |
$16,570.94
|
| Rate for Payer: Preferred Network Access Commercial |
$19,056.59
|
| Rate for Payer: Quartz Beloit One Network |
$10,149.70
|
| Rate for Payer: Quartz Commercial |
$12,428.21
|
| Rate for Payer: WEA Trust Commercial |
$11,392.52
|
| Rate for Payer: WPS Commercial |
$15,342.07
|
|
|
FEMORAL COMPONENT SZ D LT LCCK 5994-14-91
|
Facility
|
IP
|
$41,001.00
|
|
| Hospital Charge Code |
2974026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,894.11 |
| Max. Negotiated Rate |
$39,229.76 |
| Rate for Payer: Aetna Commercial |
$38,376.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36,671.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,599.75
|
| Rate for Payer: Cash Price |
$12,300.30
|
| Rate for Payer: Cigna Commercial |
$39,229.76
|
| Rate for Payer: Health EOS Commercial |
$37,950.53
|
| Rate for Payer: HFN Commercial |
$39,229.76
|
| Rate for Payer: Multiplan Commercial |
$34,112.83
|
| Rate for Payer: Preferred Network Access Commercial |
$39,229.76
|
| Rate for Payer: Quartz Beloit One Network |
$20,894.11
|
| Rate for Payer: Quartz Commercial |
$25,584.62
|
| Rate for Payer: WEA Trust Commercial |
$23,452.57
|
| Rate for Payer: WPS Commercial |
$31,583.07
|
|
|
FEMORAL COMPONENT SZ D LT LCCK 5994-14-91
|
Facility
|
OP
|
$41,001.00
|
|
| Hospital Charge Code |
2974026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,939.49 |
| Max. Negotiated Rate |
$39,229.76 |
| Rate for Payer: Aetna Commercial |
$38,376.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36,671.29
|
| Rate for Payer: Aetna Managed Medicare |
$11,939.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,716.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,320.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,467.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,599.75
|
| Rate for Payer: Cash Price |
$12,300.30
|
| Rate for Payer: Cigna Commercial |
$39,229.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,862.58
|
| Rate for Payer: Health EOS Commercial |
$37,950.53
|
| Rate for Payer: HFN Commercial |
$39,229.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,980.78
|
| Rate for Payer: Multiplan Commercial |
$34,112.83
|
| Rate for Payer: NAPHCARE Commercial |
$25,584.62
|
| Rate for Payer: Preferred Network Access Commercial |
$39,229.76
|
| Rate for Payer: Quartz Beloit One Network |
$20,894.11
|
| Rate for Payer: Quartz Commercial |
$27,716.68
|
| Rate for Payer: Quartz Medicare Advantage |
$25,584.62
|
| Rate for Payer: The Alliance Commercial |
$21,320.52
|
| Rate for Payer: WEA Trust Commercial |
$23,452.57
|
| Rate for Payer: WPS Commercial |
$31,583.07
|
|
|
FEMORAL COMPONENT SZ D RT LCCK 5994-14-92
|
Facility
|
IP
|
$31,995.00
|
|
| Hospital Charge Code |
2974019
|
|
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 COMPONENT SZ D RT LCCK 5994-14-92
|
Facility
|
OP
|
$31,995.00
|
|
| Hospital Charge Code |
2974019
|
|
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 COMPONENT SZ E LT LCCK 5994-15-91
|
Facility
|
OP
|
$31,995.00
|
|
| Hospital Charge Code |
2974021
|
|
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 COMPONENT SZ E LT LCCK 5994-15-91
|
Facility
|
IP
|
$31,995.00
|
|
| Hospital Charge Code |
2974021
|
|
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 COMPONENT SZ E RT LCCK 599401592
|
Facility
|
IP
|
$31,995.00
|
|
| Hospital Charge Code |
2974023
|
|
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 COMPONENT SZ E RT LCCK 599401592
|
Facility
|
OP
|
$31,995.00
|
|
| Hospital Charge Code |
2974023
|
|
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 COMPONENT SZ F LT LCCK 5994-16-91
|
Facility
|
OP
|
$37,362.00
|
|
| Hospital Charge Code |
2974024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,879.81 |
| Max. Negotiated Rate |
$35,747.96 |
| Rate for Payer: Aetna Commercial |
$34,970.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,416.57
|
| Rate for Payer: Aetna Managed Medicare |
$10,879.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,256.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,428.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,651.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,593.93
|
| Rate for Payer: Cash Price |
$11,208.60
|
| Rate for Payer: Cigna Commercial |
$35,747.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,744.68
|
| Rate for Payer: Health EOS Commercial |
$34,582.27
|
| Rate for Payer: HFN Commercial |
$35,747.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,142.36
|
| Rate for Payer: Multiplan Commercial |
$31,085.18
|
| Rate for Payer: NAPHCARE Commercial |
$23,313.89
|
| Rate for Payer: Preferred Network Access Commercial |
$35,747.96
|
| Rate for Payer: Quartz Beloit One Network |
$19,039.68
|
| Rate for Payer: Quartz Commercial |
$25,256.71
|
| Rate for Payer: Quartz Medicare Advantage |
$23,313.89
|
| Rate for Payer: The Alliance Commercial |
$19,428.24
|
| Rate for Payer: WEA Trust Commercial |
$21,371.06
|
| Rate for Payer: WPS Commercial |
$28,779.95
|
|
|
FEMORAL COMPONENT SZ F LT LCCK 5994-16-91
|
Facility
|
IP
|
$37,362.00
|
|
| Hospital Charge Code |
2974024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,039.68 |
| Max. Negotiated Rate |
$35,747.96 |
| Rate for Payer: Aetna Commercial |
$34,970.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,416.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,593.93
|
| Rate for Payer: Cash Price |
$11,208.60
|
| Rate for Payer: Cigna Commercial |
$35,747.96
|
| Rate for Payer: Health EOS Commercial |
$34,582.27
|
| Rate for Payer: HFN Commercial |
$35,747.96
|
| Rate for Payer: Multiplan Commercial |
$31,085.18
|
| Rate for Payer: Preferred Network Access Commercial |
$35,747.96
|
| Rate for Payer: Quartz Beloit One Network |
$19,039.68
|
| Rate for Payer: Quartz Commercial |
$23,313.89
|
| Rate for Payer: WEA Trust Commercial |
$21,371.06
|
| Rate for Payer: WPS Commercial |
$28,779.95
|
|
|
FEMORAL COMPONENT SZ F RT LCCK 5994-16-92
|
Facility
|
OP
|
$31,995.00
|
|
| Hospital Charge Code |
2974029
|
|
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 COMPONENT SZ F RT LCCK 5994-16-92
|
Facility
|
IP
|
$31,995.00
|
|
| Hospital Charge Code |
2974029
|
|
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 COMPONENT TRIATHLON TS SZ 4 RT 5512-F-402
|
Facility
|
IP
|
$27,557.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246163
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,043.24 |
| Max. Negotiated Rate |
$26,366.89 |
| Rate for Payer: Aetna Commercial |
$25,793.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24,647.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15,189.62
|
| Rate for Payer: Cash Price |
$8,267.21
|
| Rate for Payer: Cigna Commercial |
$26,366.89
|
| Rate for Payer: Health EOS Commercial |
$25,507.10
|
| Rate for Payer: HFN Commercial |
$26,366.89
|
| Rate for Payer: Multiplan Commercial |
$22,927.73
|
| Rate for Payer: Preferred Network Access Commercial |
$26,366.89
|
| Rate for Payer: Quartz Beloit One Network |
$14,043.24
|
| Rate for Payer: Quartz Commercial |
$17,195.80
|
| Rate for Payer: WEA Trust Commercial |
$15,762.82
|
| Rate for Payer: WPS Commercial |
$21,227.44
|
|
|
FEMORAL COMPONENT TRIATHLON TS SZ 4 RT 5512-F-402
|
Facility
|
OP
|
$27,557.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246163
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,024.71 |
| Max. Negotiated Rate |
$26,366.89 |
| Rate for Payer: Aetna Commercial |
$25,793.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24,647.31
|
| Rate for Payer: Aetna Managed Medicare |
$8,024.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,628.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,329.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,756.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15,189.62
|
| Rate for Payer: Cash Price |
$8,267.21
|
| Rate for Payer: Cigna Commercial |
$26,366.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16,038.39
|
| Rate for Payer: Health EOS Commercial |
$25,507.10
|
| Rate for Payer: HFN Commercial |
$26,366.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,494.75
|
| Rate for Payer: Multiplan Commercial |
$22,927.73
|
| Rate for Payer: NAPHCARE Commercial |
$17,195.80
|
| Rate for Payer: Preferred Network Access Commercial |
$26,366.89
|
| Rate for Payer: Quartz Beloit One Network |
$14,043.24
|
| Rate for Payer: Quartz Commercial |
$18,628.78
|
| Rate for Payer: Quartz Medicare Advantage |
$17,195.80
|
| Rate for Payer: The Alliance Commercial |
$14,329.83
|
| Rate for Payer: WEA Trust Commercial |
$15,762.82
|
| Rate for Payer: WPS Commercial |
$21,227.44
|
|
|
FEMORAL COMPONENT TRIATHLON TS SZ 6 LT 5512-F-601
|
Facility
|
OP
|
$37,373.00
|
|
| Hospital Charge Code |
4100374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,883.02 |
| Max. Negotiated Rate |
$35,758.49 |
| Rate for Payer: Aetna Commercial |
$34,981.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,426.41
|
| Rate for Payer: Aetna Managed Medicare |
$10,883.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,264.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,433.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,656.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,600.00
|
| Rate for Payer: Cash Price |
$11,211.90
|
| Rate for Payer: Cigna Commercial |
$35,758.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,751.09
|
| Rate for Payer: Health EOS Commercial |
$34,592.45
|
| Rate for Payer: HFN Commercial |
$35,758.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,150.94
|
| Rate for Payer: Multiplan Commercial |
$31,094.34
|
| Rate for Payer: NAPHCARE Commercial |
$23,320.75
|
| Rate for Payer: Preferred Network Access Commercial |
$35,758.49
|
| Rate for Payer: Quartz Beloit One Network |
$19,045.28
|
| Rate for Payer: Quartz Commercial |
$25,264.15
|
| Rate for Payer: Quartz Medicare Advantage |
$23,320.75
|
| Rate for Payer: The Alliance Commercial |
$19,433.96
|
| Rate for Payer: WEA Trust Commercial |
$21,377.36
|
| Rate for Payer: WPS Commercial |
$28,788.42
|
|
|
FEMORAL COMPONENT TRIATHLON TS SZ 6 LT 5512-F-601
|
Facility
|
IP
|
$37,373.00
|
|
| Hospital Charge Code |
4100374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,045.28 |
| Max. Negotiated Rate |
$35,758.49 |
| Rate for Payer: Aetna Commercial |
$34,981.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,426.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,600.00
|
| Rate for Payer: Cash Price |
$11,211.90
|
| Rate for Payer: Cigna Commercial |
$35,758.49
|
| Rate for Payer: Health EOS Commercial |
$34,592.45
|
| Rate for Payer: HFN Commercial |
$35,758.49
|
| Rate for Payer: Multiplan Commercial |
$31,094.34
|
| Rate for Payer: Preferred Network Access Commercial |
$35,758.49
|
| Rate for Payer: Quartz Beloit One Network |
$19,045.28
|
| Rate for Payer: Quartz Commercial |
$23,320.75
|
| Rate for Payer: WEA Trust Commercial |
$21,377.36
|
| Rate for Payer: WPS Commercial |
$28,788.42
|
|
|
FEMORAL CORTICAL STRUT 3-12MM THICK X 100MM LONG X 20MM WIDE FREEZE DRIED 400610
|
Facility
|
IP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
4509109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,640.75 |
| Max. Negotiated Rate |
$4,958.14 |
| Rate for Payer: Aetna Commercial |
$4,850.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,634.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,856.32
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,958.14
|
| Rate for Payer: Health EOS Commercial |
$4,796.46
|
| Rate for Payer: HFN Commercial |
$4,958.14
|
| Rate for Payer: Multiplan Commercial |
$4,311.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,958.14
|
| Rate for Payer: Quartz Beloit One Network |
$2,640.75
|
| Rate for Payer: Quartz Commercial |
$3,233.57
|
| Rate for Payer: WEA Trust Commercial |
$2,964.10
|
| Rate for Payer: WPS Commercial |
$3,991.69
|
|
|
FEMORAL CORTICAL STRUT 3-12MM THICK X 100MM LONG X 20MM WIDE FREEZE DRIED 400610
|
Facility
|
OP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
4509109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,509.00 |
| Max. Negotiated Rate |
$4,958.14 |
| Rate for Payer: Aetna Commercial |
$4,850.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,634.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,509.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,503.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,694.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,586.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,856.32
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,958.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,015.92
|
| Rate for Payer: Health EOS Commercial |
$4,796.46
|
| Rate for Payer: HFN Commercial |
$4,958.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,041.96
|
| Rate for Payer: Multiplan Commercial |
$4,311.42
|
| Rate for Payer: NAPHCARE Commercial |
$3,233.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,958.14
|
| Rate for Payer: Quartz Beloit One Network |
$2,640.75
|
| Rate for Payer: Quartz Commercial |
$3,503.03
|
| Rate for Payer: Quartz Medicare Advantage |
$3,233.57
|
| Rate for Payer: The Alliance Commercial |
$2,694.64
|
| Rate for Payer: WEA Trust Commercial |
$2,964.10
|
| Rate for Payer: WPS Commercial |
$3,991.69
|
|
|
FEMORAL CORTICAL STRUT HALF 15CM 450485
|
Facility
|
OP
|
$6,757.00
|
|
| Hospital Charge Code |
3657496
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,967.64 |
| Max. Negotiated Rate |
$6,465.10 |
| Rate for Payer: Aetna Commercial |
$6,324.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,043.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,967.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,567.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,513.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,373.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,724.46
|
| Rate for Payer: Cash Price |
$2,027.10
|
| Rate for Payer: Cigna Commercial |
$6,465.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,932.57
|
| Rate for Payer: Health EOS Commercial |
$6,254.28
|
| Rate for Payer: HFN Commercial |
$6,465.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,270.46
|
| Rate for Payer: Multiplan Commercial |
$5,621.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,216.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6,465.10
|
| Rate for Payer: Quartz Beloit One Network |
$3,443.37
|
| Rate for Payer: Quartz Commercial |
$4,567.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4,216.37
|
| Rate for Payer: The Alliance Commercial |
$3,513.64
|
| Rate for Payer: WEA Trust Commercial |
$3,865.00
|
| Rate for Payer: WPS Commercial |
$5,204.92
|
|
|
FEMORAL CORTICAL STRUT HALF 15CM 450485
|
Facility
|
IP
|
$6,757.00
|
|
| Hospital Charge Code |
3657496
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,443.37 |
| Max. Negotiated Rate |
$6,465.10 |
| Rate for Payer: Aetna Commercial |
$6,324.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,043.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,724.46
|
| Rate for Payer: Cash Price |
$2,027.10
|
| Rate for Payer: Cigna Commercial |
$6,465.10
|
| Rate for Payer: Health EOS Commercial |
$6,254.28
|
| Rate for Payer: HFN Commercial |
$6,465.10
|
| Rate for Payer: Multiplan Commercial |
$5,621.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6,465.10
|
| Rate for Payer: Quartz Beloit One Network |
$3,443.37
|
| Rate for Payer: Quartz Commercial |
$4,216.37
|
| Rate for Payer: WEA Trust Commercial |
$3,865.00
|
| Rate for Payer: WPS Commercial |
$5,204.92
|
|
|
FEMORAL CR SIGMA CEMENTED SZ 4 LT 1960-00-400
|
Facility
|
OP
|
$6,176.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,798.45 |
| Max. Negotiated Rate |
$5,909.20 |
| Rate for Payer: Aetna Commercial |
$5,780.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,523.81
|
| Rate for Payer: Aetna Managed Medicare |
$1,798.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,174.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,211.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,083.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,404.21
|
| Rate for Payer: Cash Price |
$1,852.80
|
| Rate for Payer: Cigna Commercial |
$5,909.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,594.43
|
| Rate for Payer: Health EOS Commercial |
$5,716.51
|
| Rate for Payer: HFN Commercial |
$5,909.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,817.28
|
| Rate for Payer: Multiplan Commercial |
$5,138.43
|
| Rate for Payer: NAPHCARE Commercial |
$3,853.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,909.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,147.29
|
| Rate for Payer: Quartz Commercial |
$4,174.98
|
| Rate for Payer: Quartz Medicare Advantage |
$3,853.82
|
| Rate for Payer: The Alliance Commercial |
$3,211.52
|
| Rate for Payer: WEA Trust Commercial |
$3,532.67
|
| Rate for Payer: WPS Commercial |
$4,757.37
|
|
|
FEMORAL CR SIGMA CEMENTED SZ 4 LT 1960-00-400
|
Facility
|
IP
|
$6,176.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,147.29 |
| Max. Negotiated Rate |
$5,909.20 |
| Rate for Payer: Aetna Commercial |
$5,780.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,523.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,404.21
|
| Rate for Payer: Cash Price |
$1,852.80
|
| Rate for Payer: Cigna Commercial |
$5,909.20
|
| Rate for Payer: Health EOS Commercial |
$5,716.51
|
| Rate for Payer: HFN Commercial |
$5,909.20
|
| Rate for Payer: Multiplan Commercial |
$5,138.43
|
| Rate for Payer: Preferred Network Access Commercial |
$5,909.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,147.29
|
| Rate for Payer: Quartz Commercial |
$3,853.82
|
| Rate for Payer: WEA Trust Commercial |
$3,532.67
|
| Rate for Payer: WPS Commercial |
$4,757.37
|
|
|
FEMORAL FEMORAL BYPASS GRAFT
|
Facility
|
IP
|
$16,743.00
|
|
| Hospital Charge Code |
2960066
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,532.23 |
| Max. Negotiated Rate |
$16,019.70 |
| Rate for Payer: Aetna Commercial |
$15,671.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,974.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,228.74
|
| Rate for Payer: Cash Price |
$5,022.90
|
| Rate for Payer: Cigna Commercial |
$16,019.70
|
| Rate for Payer: Health EOS Commercial |
$15,497.32
|
| Rate for Payer: HFN Commercial |
$16,019.70
|
| Rate for Payer: Multiplan Commercial |
$13,930.18
|
| Rate for Payer: Preferred Network Access Commercial |
$16,019.70
|
| Rate for Payer: Quartz Beloit One Network |
$8,532.23
|
| Rate for Payer: Quartz Commercial |
$10,447.63
|
| Rate for Payer: WEA Trust Commercial |
$9,577.00
|
| Rate for Payer: WPS Commercial |
$12,897.13
|
|
