|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 7 4MM CEMENTED 1549-07-001
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,736.56 |
| Max. Negotiated Rate |
$24,808.00 |
| Rate for Payer: Aetna Commercial |
$5,581.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,736.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,031.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,976.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.06
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,705.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,470.64
|
| Rate for Payer: Health EOS Commercial |
$5,519.78
|
| Rate for Payer: HFN Commercial |
$5,705.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,651.50
|
| Rate for Payer: Multiplan Commercial |
$4,961.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,721.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.98
|
| Rate for Payer: Quartz Commercial |
$4,031.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,721.20
|
| Rate for Payer: The Alliance Commercial |
$24,808.00
|
| Rate for Payer: WEA Trust Commercial |
$3,411.10
|
| Rate for Payer: WPS Commercial |
$4,593.82
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 7 8MM CEMENTED 1549-07-002
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,736.56 |
| Max. Negotiated Rate |
$24,808.00 |
| Rate for Payer: Aetna Commercial |
$5,581.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,736.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,031.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,976.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.06
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,705.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,470.64
|
| Rate for Payer: Health EOS Commercial |
$5,519.78
|
| Rate for Payer: HFN Commercial |
$5,705.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,651.50
|
| Rate for Payer: Multiplan Commercial |
$4,961.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,721.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.98
|
| Rate for Payer: Quartz Commercial |
$4,031.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,721.20
|
| Rate for Payer: The Alliance Commercial |
$24,808.00
|
| Rate for Payer: WEA Trust Commercial |
$3,411.10
|
| Rate for Payer: WPS Commercial |
$4,593.82
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 7 8MM CEMENTED 1549-07-002
|
Facility
|
IP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,038.98 |
| Max. Negotiated Rate |
$5,705.84 |
| Rate for Payer: Aetna Commercial |
$5,581.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.06
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,705.84
|
| Rate for Payer: Health EOS Commercial |
$5,519.78
|
| Rate for Payer: HFN Commercial |
$5,705.84
|
| Rate for Payer: Multiplan Commercial |
$4,961.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,721.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.98
|
| Rate for Payer: Quartz Commercial |
$3,721.20
|
| Rate for Payer: WEA Trust Commercial |
$3,411.10
|
| Rate for Payer: WPS Commercial |
$4,593.82
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 8 8MM CEMENTED 1549-08-002
|
Facility
|
OP
|
$5,963.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,669.64 |
| Max. Negotiated Rate |
$23,852.00 |
| Rate for Payer: Aetna Commercial |
$5,366.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,128.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,669.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,875.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,981.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,862.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,160.39
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,485.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,336.89
|
| Rate for Payer: Health EOS Commercial |
$5,307.07
|
| Rate for Payer: HFN Commercial |
$5,485.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,472.25
|
| Rate for Payer: Multiplan Commercial |
$4,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,485.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,921.87
|
| Rate for Payer: Quartz Commercial |
$3,875.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,577.80
|
| Rate for Payer: The Alliance Commercial |
$23,852.00
|
| Rate for Payer: WEA Trust Commercial |
$3,279.65
|
| Rate for Payer: WPS Commercial |
$4,416.79
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 8 8MM CEMENTED 1549-08-002
|
Facility
|
IP
|
$5,963.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,921.87 |
| Max. Negotiated Rate |
$5,485.96 |
| Rate for Payer: Aetna Commercial |
$5,366.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,128.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,160.39
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,485.96
|
| Rate for Payer: Health EOS Commercial |
$5,307.07
|
| Rate for Payer: HFN Commercial |
$5,485.96
|
| Rate for Payer: Multiplan Commercial |
$4,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,485.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,921.87
|
| Rate for Payer: Quartz Commercial |
$3,577.80
|
| Rate for Payer: WEA Trust Commercial |
$3,279.65
|
| Rate for Payer: WPS Commercial |
$4,416.79
|
|
|
FEMORAL CANAL PRESSURIZER W/O HUB MEDIUM 0206-546-000
|
Facility
|
IP
|
$498.00
|
|
| Hospital Charge Code |
2963268
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.02 |
| Max. Negotiated Rate |
$458.16 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.94
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$298.80
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$298.80
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
FEMORAL CANAL PRESSURIZER W/O HUB MEDIUM 0206-546-000
|
Facility
|
OP
|
$498.00
|
|
| Hospital Charge Code |
2963268
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.44 |
| Max. Negotiated Rate |
$1,992.00 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Aetna Managed Medicare |
$139.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$239.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.94
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.68
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$373.50
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$298.80
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$323.70
|
| Rate for Payer: Quartz Medicare Advantage |
$298.80
|
| Rate for Payer: The Alliance Commercial |
$1,992.00
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
FEMORAL CANAL PRESSURIZER W/O HUB SMALL 0206-545-000
|
Facility
|
IP
|
$498.00
|
|
| Hospital Charge Code |
2963803
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.02 |
| Max. Negotiated Rate |
$458.16 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.94
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$298.80
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$298.80
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
FEMORAL CANAL PRESSURIZER W/O HUB SMALL 0206-545-000
|
Facility
|
OP
|
$498.00
|
|
| Hospital Charge Code |
2963803
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.44 |
| Max. Negotiated Rate |
$1,992.00 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Aetna Managed Medicare |
$139.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$239.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.94
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.68
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$373.50
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$298.80
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$323.70
|
| Rate for Payer: Quartz Medicare Advantage |
$298.80
|
| Rate for Payer: The Alliance Commercial |
$1,992.00
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
FEMORAL COMP C-LT LPS FLEX GSF 00-5764-013-51
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
FEMORAL COMP C-LT LPS FLEX GSF 00-5764-013-51
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,031.32 |
| Max. Negotiated Rate |
$71,876.00 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,031.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,679.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,625.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,055.45
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,476.75
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$11,679.85
|
| Rate for Payer: Quartz Medicare Advantage |
$10,781.40
|
| Rate for Payer: The Alliance Commercial |
$71,876.00
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
FEMORAL COMP C-RT LPS FLEX GSF 00-5764-013-52
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,031.32 |
| Max. Negotiated Rate |
$71,876.00 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,031.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,679.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,625.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,055.45
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,476.75
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$11,679.85
|
| Rate for Payer: Quartz Medicare Advantage |
$10,781.40
|
| Rate for Payer: The Alliance Commercial |
$71,876.00
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
FEMORAL COMP C-RT LPS FLEX GSF 00-5764-013-52
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
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 |
$9,113.02 |
| Max. Negotiated Rate |
$17,110.16 |
| Rate for Payer: Aetna Commercial |
$16,738.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,994.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,856.94
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,110.16
|
| Rate for Payer: Health EOS Commercial |
$16,552.22
|
| Rate for Payer: HFN Commercial |
$17,110.16
|
| Rate for Payer: Multiplan Commercial |
$14,878.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,158.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,110.16
|
| Rate for Payer: Quartz Beloit One Network |
$9,113.02
|
| Rate for Payer: Quartz Commercial |
$11,158.80
|
| Rate for Payer: WEA Trust Commercial |
$10,228.90
|
| Rate for Payer: WPS Commercial |
$13,775.54
|
|
|
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 |
$5,207.44 |
| Max. Negotiated Rate |
$74,392.00 |
| Rate for Payer: Aetna Commercial |
$16,738.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,994.28
|
| Rate for Payer: Aetna Managed Medicare |
$5,207.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,088.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,927.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,856.94
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,110.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,407.44
|
| Rate for Payer: Health EOS Commercial |
$16,552.22
|
| Rate for Payer: HFN Commercial |
$17,110.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,948.50
|
| Rate for Payer: Multiplan Commercial |
$14,878.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,158.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,110.16
|
| Rate for Payer: Quartz Beloit One Network |
$9,113.02
|
| Rate for Payer: Quartz Commercial |
$12,088.70
|
| Rate for Payer: Quartz Medicare Advantage |
$11,158.80
|
| Rate for Payer: The Alliance Commercial |
$74,392.00
|
| Rate for Payer: WEA Trust Commercial |
$10,228.90
|
| Rate for Payer: WPS Commercial |
$13,775.54
|
|
|
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 |
$5,031.32 |
| Max. Negotiated Rate |
$71,876.00 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,031.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,679.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,625.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,055.45
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,476.75
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$11,679.85
|
| Rate for Payer: Quartz Medicare Advantage |
$10,781.40
|
| Rate for Payer: The Alliance Commercial |
$71,876.00
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
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 |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
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 |
$5,207.44 |
| Max. Negotiated Rate |
$74,392.00 |
| Rate for Payer: Aetna Commercial |
$16,738.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,994.28
|
| Rate for Payer: Aetna Managed Medicare |
$5,207.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,088.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,927.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,856.94
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,110.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,407.44
|
| Rate for Payer: Health EOS Commercial |
$16,552.22
|
| Rate for Payer: HFN Commercial |
$17,110.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,948.50
|
| Rate for Payer: Multiplan Commercial |
$14,878.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,158.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,110.16
|
| Rate for Payer: Quartz Beloit One Network |
$9,113.02
|
| Rate for Payer: Quartz Commercial |
$12,088.70
|
| Rate for Payer: Quartz Medicare Advantage |
$11,158.80
|
| Rate for Payer: The Alliance Commercial |
$74,392.00
|
| Rate for Payer: WEA Trust Commercial |
$10,228.90
|
| Rate for Payer: WPS Commercial |
$13,775.54
|
|
|
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 |
$9,113.02 |
| Max. Negotiated Rate |
$17,110.16 |
| Rate for Payer: Aetna Commercial |
$16,738.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,994.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,856.94
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,110.16
|
| Rate for Payer: Health EOS Commercial |
$16,552.22
|
| Rate for Payer: HFN Commercial |
$17,110.16
|
| Rate for Payer: Multiplan Commercial |
$14,878.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,158.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,110.16
|
| Rate for Payer: Quartz Beloit One Network |
$9,113.02
|
| Rate for Payer: Quartz Commercial |
$11,158.80
|
| Rate for Payer: WEA Trust Commercial |
$10,228.90
|
| Rate for Payer: WPS Commercial |
$13,775.54
|
|
|
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 |
$5,031.32 |
| Max. Negotiated Rate |
$71,876.00 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,031.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,679.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,625.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,055.45
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,476.75
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$11,679.85
|
| Rate for Payer: Quartz Medicare Advantage |
$10,781.40
|
| Rate for Payer: The Alliance Commercial |
$71,876.00
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
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 |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
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 |
$5,207.44 |
| Max. Negotiated Rate |
$74,392.00 |
| Rate for Payer: Aetna Commercial |
$16,738.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,994.28
|
| Rate for Payer: Aetna Managed Medicare |
$5,207.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,088.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,927.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,856.94
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,110.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,407.44
|
| Rate for Payer: Health EOS Commercial |
$16,552.22
|
| Rate for Payer: HFN Commercial |
$17,110.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,948.50
|
| Rate for Payer: Multiplan Commercial |
$14,878.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,158.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,110.16
|
| Rate for Payer: Quartz Beloit One Network |
$9,113.02
|
| Rate for Payer: Quartz Commercial |
$12,088.70
|
| Rate for Payer: Quartz Medicare Advantage |
$11,158.80
|
| Rate for Payer: The Alliance Commercial |
$74,392.00
|
| Rate for Payer: WEA Trust Commercial |
$10,228.90
|
| Rate for Payer: WPS Commercial |
$13,775.54
|
|
|
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 |
$9,113.02 |
| Max. Negotiated Rate |
$17,110.16 |
| Rate for Payer: Aetna Commercial |
$16,738.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,994.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,856.94
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,110.16
|
| Rate for Payer: Health EOS Commercial |
$16,552.22
|
| Rate for Payer: HFN Commercial |
$17,110.16
|
| Rate for Payer: Multiplan Commercial |
$14,878.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,158.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,110.16
|
| Rate for Payer: Quartz Beloit One Network |
$9,113.02
|
| Rate for Payer: Quartz Commercial |
$11,158.80
|
| Rate for Payer: WEA Trust Commercial |
$10,228.90
|
| Rate for Payer: WPS Commercial |
$13,775.54
|
|
|
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 |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
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 |
$5,031.32 |
| Max. Negotiated Rate |
$71,876.00 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,031.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,679.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,625.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,055.45
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,476.75
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$11,679.85
|
| Rate for Payer: Quartz Medicare Advantage |
$10,781.40
|
| Rate for Payer: The Alliance Commercial |
$71,876.00
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
