|
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 |
$5,585.02 |
| Max. Negotiated Rate |
$10,486.16 |
| Rate for Payer: Aetna Commercial |
$10,258.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,802.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,040.94
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,486.16
|
| Rate for Payer: Health EOS Commercial |
$10,144.22
|
| Rate for Payer: HFN Commercial |
$10,486.16
|
| Rate for Payer: Multiplan Commercial |
$9,118.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,838.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,486.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,585.02
|
| Rate for Payer: Quartz Commercial |
$6,838.80
|
| Rate for Payer: WEA Trust Commercial |
$6,268.90
|
| Rate for Payer: WPS Commercial |
$8,442.50
|
|
|
FEMORAL COMPONENT 3 LT OXINIUM 7141213
|
Facility
|
IP
|
$34,168.00
|
|
| Hospital Charge Code |
2966011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,742.32 |
| Max. Negotiated Rate |
$31,434.56 |
| Rate for Payer: Aetna Commercial |
$30,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29,384.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,109.04
|
| Rate for Payer: Cash Price |
$10,250.40
|
| Rate for Payer: Cigna Commercial |
$31,434.56
|
| Rate for Payer: Health EOS Commercial |
$30,409.52
|
| Rate for Payer: HFN Commercial |
$31,434.56
|
| Rate for Payer: Multiplan Commercial |
$27,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$20,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$31,434.56
|
| Rate for Payer: Quartz Beloit One Network |
$16,742.32
|
| Rate for Payer: Quartz Commercial |
$20,500.80
|
| Rate for Payer: WEA Trust Commercial |
$18,792.40
|
| Rate for Payer: WPS Commercial |
$25,308.24
|
|
|
FEMORAL COMPONENT 3 LT OXINIUM 7141213
|
Facility
|
OP
|
$34,168.00
|
|
| Hospital Charge Code |
2966011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,567.04 |
| Max. Negotiated Rate |
$136,672.00 |
| Rate for Payer: Aetna Commercial |
$30,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29,384.48
|
| Rate for Payer: Aetna Managed Medicare |
$9,567.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,209.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,084.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,400.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,109.04
|
| Rate for Payer: Cash Price |
$10,250.40
|
| Rate for Payer: Cigna Commercial |
$31,434.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,120.41
|
| Rate for Payer: Health EOS Commercial |
$30,409.52
|
| Rate for Payer: HFN Commercial |
$31,434.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,626.00
|
| Rate for Payer: Multiplan Commercial |
$27,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$20,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$31,434.56
|
| Rate for Payer: Quartz Beloit One Network |
$16,742.32
|
| Rate for Payer: Quartz Commercial |
$22,209.20
|
| Rate for Payer: Quartz Medicare Advantage |
$20,500.80
|
| Rate for Payer: The Alliance Commercial |
$136,672.00
|
| Rate for Payer: WEA Trust Commercial |
$18,792.40
|
| Rate for Payer: WPS Commercial |
$25,308.24
|
|
|
FEMORAL COMPONENT 6.0x2.0x1.0
|
Facility
|
OP
|
$12,202.00
|
|
| Hospital Charge Code |
2964728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
FEMORAL COMPONENT 6.0x2.0x1.0
|
Facility
|
IP
|
$12,202.00
|
|
| Hospital Charge Code |
2964728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
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 |
$4,216.94 |
| Max. Negotiated Rate |
$7,917.52 |
| Rate for Payer: Aetna Commercial |
$7,745.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,401.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,561.18
|
| Rate for Payer: Cash Price |
$2,581.80
|
| Rate for Payer: Cigna Commercial |
$7,917.52
|
| Rate for Payer: Health EOS Commercial |
$7,659.34
|
| Rate for Payer: HFN Commercial |
$7,917.52
|
| Rate for Payer: Multiplan Commercial |
$6,884.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,163.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,917.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,216.94
|
| Rate for Payer: Quartz Commercial |
$5,163.60
|
| Rate for Payer: WEA Trust Commercial |
$4,733.30
|
| Rate for Payer: WPS Commercial |
$6,374.46
|
|
|
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 |
$2,409.68 |
| Max. Negotiated Rate |
$34,424.00 |
| Rate for Payer: Aetna Commercial |
$7,745.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,401.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,409.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,593.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,303.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,130.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,561.18
|
| Rate for Payer: Cash Price |
$2,581.80
|
| Rate for Payer: Cigna Commercial |
$7,917.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,815.92
|
| Rate for Payer: Health EOS Commercial |
$7,659.34
|
| Rate for Payer: HFN Commercial |
$7,917.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,454.50
|
| Rate for Payer: Multiplan Commercial |
$6,884.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,163.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,917.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,216.94
|
| Rate for Payer: Quartz Commercial |
$5,593.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,163.60
|
| Rate for Payer: The Alliance Commercial |
$34,424.00
|
| Rate for Payer: WEA Trust Commercial |
$4,733.30
|
| Rate for Payer: WPS Commercial |
$6,374.46
|
|
|
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 |
$5,207.44 |
| 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 COMPONENT C-LT LPS FLEX 5960-13-51
|
Facility
|
IP
|
$18,598.00
|
|
| Hospital Charge Code |
3259461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,113.02 |
| 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 COMPONENT D LEFT
|
Facility
|
OP
|
$22,690.00
|
|
| Hospital Charge Code |
2967470
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,353.20 |
| Max. Negotiated Rate |
$90,760.00 |
| Rate for Payer: Aetna Commercial |
$20,421.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,513.40
|
| Rate for Payer: Aetna Managed Medicare |
$6,353.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,748.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,345.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,891.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,025.70
|
| Rate for Payer: Cash Price |
$6,807.00
|
| Rate for Payer: Cigna Commercial |
$20,874.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,697.32
|
| Rate for Payer: Health EOS Commercial |
$20,194.10
|
| Rate for Payer: HFN Commercial |
$20,874.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,017.50
|
| Rate for Payer: Multiplan Commercial |
$18,152.00
|
| Rate for Payer: NAPHCARE Commercial |
$13,614.00
|
| Rate for Payer: Preferred Network Access Commercial |
$20,874.80
|
| Rate for Payer: Quartz Beloit One Network |
$11,118.10
|
| Rate for Payer: Quartz Commercial |
$14,748.50
|
| Rate for Payer: Quartz Medicare Advantage |
$13,614.00
|
| Rate for Payer: The Alliance Commercial |
$90,760.00
|
| Rate for Payer: WEA Trust Commercial |
$12,479.50
|
| Rate for Payer: WPS Commercial |
$16,806.48
|
|
|
FEMORAL COMPONENT D LEFT
|
Facility
|
IP
|
$22,690.00
|
|
| Hospital Charge Code |
2967470
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,118.10 |
| Max. Negotiated Rate |
$20,874.80 |
| Rate for Payer: Aetna Commercial |
$20,421.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,513.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,025.70
|
| Rate for Payer: Cash Price |
$6,807.00
|
| Rate for Payer: Cigna Commercial |
$20,874.80
|
| Rate for Payer: Health EOS Commercial |
$20,194.10
|
| Rate for Payer: HFN Commercial |
$20,874.80
|
| Rate for Payer: Multiplan Commercial |
$18,152.00
|
| Rate for Payer: NAPHCARE Commercial |
$13,614.00
|
| Rate for Payer: Preferred Network Access Commercial |
$20,874.80
|
| Rate for Payer: Quartz Beloit One Network |
$11,118.10
|
| Rate for Payer: Quartz Commercial |
$13,614.00
|
| Rate for Payer: WEA Trust Commercial |
$12,479.50
|
| Rate for Payer: WPS Commercial |
$16,806.48
|
|
|
FEMORAL COMPONENT F RT W/TI-
|
Facility
|
IP
|
$21,849.00
|
|
| Hospital Charge Code |
2967472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,706.01 |
| Max. Negotiated Rate |
$20,101.08 |
| Rate for Payer: Aetna Commercial |
$19,664.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,790.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,579.97
|
| Rate for Payer: Cash Price |
$6,554.70
|
| Rate for Payer: Cigna Commercial |
$20,101.08
|
| Rate for Payer: Health EOS Commercial |
$19,445.61
|
| Rate for Payer: HFN Commercial |
$20,101.08
|
| Rate for Payer: Multiplan Commercial |
$17,479.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,109.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,101.08
|
| Rate for Payer: Quartz Beloit One Network |
$10,706.01
|
| Rate for Payer: Quartz Commercial |
$13,109.40
|
| Rate for Payer: WEA Trust Commercial |
$12,016.95
|
| Rate for Payer: WPS Commercial |
$16,183.55
|
|
|
FEMORAL COMPONENT F RT W/TI-
|
Facility
|
OP
|
$21,849.00
|
|
| Hospital Charge Code |
2967472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,117.72 |
| Max. Negotiated Rate |
$87,396.00 |
| Rate for Payer: Aetna Commercial |
$19,664.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,790.14
|
| Rate for Payer: Aetna Managed Medicare |
$6,117.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,201.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,924.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,487.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,579.97
|
| Rate for Payer: Cash Price |
$6,554.70
|
| Rate for Payer: Cigna Commercial |
$20,101.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,226.70
|
| Rate for Payer: Health EOS Commercial |
$19,445.61
|
| Rate for Payer: HFN Commercial |
$20,101.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,386.75
|
| Rate for Payer: Multiplan Commercial |
$17,479.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,109.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,101.08
|
| Rate for Payer: Quartz Beloit One Network |
$10,706.01
|
| Rate for Payer: Quartz Commercial |
$14,201.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13,109.40
|
| Rate for Payer: The Alliance Commercial |
$87,396.00
|
| Rate for Payer: WEA Trust Commercial |
$12,016.95
|
| Rate for Payer: WPS Commercial |
$16,183.55
|
|
|
FEMORAL COMPONENT OPTION SZ E
|
Facility
|
OP
|
$19,917.00
|
|
| Hospital Charge Code |
2967473
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,576.76 |
| Max. Negotiated Rate |
$79,668.00 |
| Rate for Payer: Aetna Commercial |
$17,925.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,128.62
|
| Rate for Payer: Aetna Managed Medicare |
$5,576.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,946.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,958.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,560.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,556.01
|
| Rate for Payer: Cash Price |
$5,975.10
|
| Rate for Payer: Cigna Commercial |
$18,323.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,145.55
|
| Rate for Payer: Health EOS Commercial |
$17,726.13
|
| Rate for Payer: HFN Commercial |
$18,323.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,937.75
|
| Rate for Payer: Multiplan Commercial |
$15,933.60
|
| Rate for Payer: NAPHCARE Commercial |
$11,950.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18,323.64
|
| Rate for Payer: Quartz Beloit One Network |
$9,759.33
|
| Rate for Payer: Quartz Commercial |
$12,946.05
|
| Rate for Payer: Quartz Medicare Advantage |
$11,950.20
|
| Rate for Payer: The Alliance Commercial |
$79,668.00
|
| Rate for Payer: WEA Trust Commercial |
$10,954.35
|
| Rate for Payer: WPS Commercial |
$14,752.52
|
|
|
FEMORAL COMPONENT OPTION SZ E
|
Facility
|
IP
|
$19,917.00
|
|
| Hospital Charge Code |
2967473
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,759.33 |
| Max. Negotiated Rate |
$18,323.64 |
| Rate for Payer: Aetna Commercial |
$17,925.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,128.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,556.01
|
| Rate for Payer: Cash Price |
$5,975.10
|
| Rate for Payer: Cigna Commercial |
$18,323.64
|
| Rate for Payer: Health EOS Commercial |
$17,726.13
|
| Rate for Payer: HFN Commercial |
$18,323.64
|
| Rate for Payer: Multiplan Commercial |
$15,933.60
|
| Rate for Payer: NAPHCARE Commercial |
$11,950.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18,323.64
|
| Rate for Payer: Quartz Beloit One Network |
$9,759.33
|
| Rate for Payer: Quartz Commercial |
$11,950.20
|
| Rate for Payer: WEA Trust Commercial |
$10,954.35
|
| Rate for Payer: WPS Commercial |
$14,752.52
|
|
|
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 |
$20,090.49 |
| Max. Negotiated Rate |
$37,720.92 |
| Rate for Payer: Aetna Commercial |
$36,900.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35,260.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21,730.53
|
| Rate for Payer: Cash Price |
$12,300.30
|
| Rate for Payer: Cigna Commercial |
$37,720.92
|
| Rate for Payer: Health EOS Commercial |
$36,490.89
|
| Rate for Payer: HFN Commercial |
$37,720.92
|
| Rate for Payer: Multiplan Commercial |
$32,800.80
|
| Rate for Payer: NAPHCARE Commercial |
$24,600.60
|
| Rate for Payer: Preferred Network Access Commercial |
$37,720.92
|
| Rate for Payer: Quartz Beloit One Network |
$20,090.49
|
| Rate for Payer: Quartz Commercial |
$24,600.60
|
| Rate for Payer: WEA Trust Commercial |
$22,550.55
|
| Rate for Payer: WPS Commercial |
$30,369.44
|
|
|
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 |
$11,480.28 |
| Max. Negotiated Rate |
$164,004.00 |
| Rate for Payer: Aetna Commercial |
$36,900.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35,260.86
|
| Rate for Payer: Aetna Managed Medicare |
$11,480.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26,650.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,500.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,680.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21,730.53
|
| Rate for Payer: Cash Price |
$12,300.30
|
| Rate for Payer: Cigna Commercial |
$37,720.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,944.16
|
| Rate for Payer: Health EOS Commercial |
$36,490.89
|
| Rate for Payer: HFN Commercial |
$37,720.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30,750.75
|
| Rate for Payer: Multiplan Commercial |
$32,800.80
|
| Rate for Payer: NAPHCARE Commercial |
$24,600.60
|
| Rate for Payer: Preferred Network Access Commercial |
$37,720.92
|
| Rate for Payer: Quartz Beloit One Network |
$20,090.49
|
| Rate for Payer: Quartz Commercial |
$26,650.65
|
| Rate for Payer: Quartz Medicare Advantage |
$24,600.60
|
| Rate for Payer: The Alliance Commercial |
$164,004.00
|
| Rate for Payer: WEA Trust Commercial |
$22,550.55
|
| Rate for Payer: WPS Commercial |
$30,369.44
|
|
|
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 |
$8,958.60 |
| Max. Negotiated Rate |
$127,980.00 |
| Rate for Payer: Aetna Commercial |
$28,795.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,515.70
|
| Rate for Payer: Aetna Managed Medicare |
$8,958.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,796.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,997.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,357.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,957.35
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$29,435.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,904.40
|
| Rate for Payer: Health EOS Commercial |
$28,475.55
|
| Rate for Payer: HFN Commercial |
$29,435.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,996.25
|
| Rate for Payer: Multiplan Commercial |
$25,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,197.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,435.40
|
| Rate for Payer: Quartz Beloit One Network |
$15,677.55
|
| Rate for Payer: Quartz Commercial |
$20,796.75
|
| Rate for Payer: Quartz Medicare Advantage |
$19,197.00
|
| Rate for Payer: The Alliance Commercial |
$127,980.00
|
| Rate for Payer: WEA Trust Commercial |
$17,597.25
|
| Rate for Payer: WPS Commercial |
$23,698.70
|
|
|
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 |
$15,677.55 |
| Max. Negotiated Rate |
$29,435.40 |
| Rate for Payer: Aetna Commercial |
$28,795.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,515.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,957.35
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$29,435.40
|
| Rate for Payer: Health EOS Commercial |
$28,475.55
|
| Rate for Payer: HFN Commercial |
$29,435.40
|
| Rate for Payer: Multiplan Commercial |
$25,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,197.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,435.40
|
| Rate for Payer: Quartz Beloit One Network |
$15,677.55
|
| Rate for Payer: Quartz Commercial |
$19,197.00
|
| Rate for Payer: WEA Trust Commercial |
$17,597.25
|
| Rate for Payer: WPS Commercial |
$23,698.70
|
|
|
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 |
$15,677.55 |
| Max. Negotiated Rate |
$29,435.40 |
| Rate for Payer: Aetna Commercial |
$28,795.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,515.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,957.35
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$29,435.40
|
| Rate for Payer: Health EOS Commercial |
$28,475.55
|
| Rate for Payer: HFN Commercial |
$29,435.40
|
| Rate for Payer: Multiplan Commercial |
$25,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,197.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,435.40
|
| Rate for Payer: Quartz Beloit One Network |
$15,677.55
|
| Rate for Payer: Quartz Commercial |
$19,197.00
|
| Rate for Payer: WEA Trust Commercial |
$17,597.25
|
| Rate for Payer: WPS Commercial |
$23,698.70
|
|
|
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 |
$8,958.60 |
| Max. Negotiated Rate |
$127,980.00 |
| Rate for Payer: Aetna Commercial |
$28,795.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,515.70
|
| Rate for Payer: Aetna Managed Medicare |
$8,958.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,796.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,997.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,357.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,957.35
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$29,435.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,904.40
|
| Rate for Payer: Health EOS Commercial |
$28,475.55
|
| Rate for Payer: HFN Commercial |
$29,435.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,996.25
|
| Rate for Payer: Multiplan Commercial |
$25,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,197.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,435.40
|
| Rate for Payer: Quartz Beloit One Network |
$15,677.55
|
| Rate for Payer: Quartz Commercial |
$20,796.75
|
| Rate for Payer: Quartz Medicare Advantage |
$19,197.00
|
| Rate for Payer: The Alliance Commercial |
$127,980.00
|
| Rate for Payer: WEA Trust Commercial |
$17,597.25
|
| Rate for Payer: WPS Commercial |
$23,698.70
|
|
|
FEMORAL COMPONENT SZ E RT LCCK 599401592
|
Facility
|
IP
|
$31,995.00
|
|
| Hospital Charge Code |
2974023
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,677.55 |
| Max. Negotiated Rate |
$29,435.40 |
| Rate for Payer: Aetna Commercial |
$28,795.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,515.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,957.35
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$29,435.40
|
| Rate for Payer: Health EOS Commercial |
$28,475.55
|
| Rate for Payer: HFN Commercial |
$29,435.40
|
| Rate for Payer: Multiplan Commercial |
$25,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,197.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,435.40
|
| Rate for Payer: Quartz Beloit One Network |
$15,677.55
|
| Rate for Payer: Quartz Commercial |
$19,197.00
|
| Rate for Payer: WEA Trust Commercial |
$17,597.25
|
| Rate for Payer: WPS Commercial |
$23,698.70
|
|
|
FEMORAL COMPONENT SZ E RT LCCK 599401592
|
Facility
|
OP
|
$31,995.00
|
|
| Hospital Charge Code |
2974023
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,958.60 |
| Max. Negotiated Rate |
$127,980.00 |
| Rate for Payer: Aetna Commercial |
$28,795.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,515.70
|
| Rate for Payer: Aetna Managed Medicare |
$8,958.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,796.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,997.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,357.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,957.35
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$29,435.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,904.40
|
| Rate for Payer: Health EOS Commercial |
$28,475.55
|
| Rate for Payer: HFN Commercial |
$29,435.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,996.25
|
| Rate for Payer: Multiplan Commercial |
$25,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,197.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,435.40
|
| Rate for Payer: Quartz Beloit One Network |
$15,677.55
|
| Rate for Payer: Quartz Commercial |
$20,796.75
|
| Rate for Payer: Quartz Medicare Advantage |
$19,197.00
|
| Rate for Payer: The Alliance Commercial |
$127,980.00
|
| Rate for Payer: WEA Trust Commercial |
$17,597.25
|
| Rate for Payer: WPS Commercial |
$23,698.70
|
|
|
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 |
$18,307.38 |
| Max. Negotiated Rate |
$34,373.04 |
| Rate for Payer: Aetna Commercial |
$33,625.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32,131.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,801.86
|
| Rate for Payer: Cash Price |
$11,208.60
|
| Rate for Payer: Cigna Commercial |
$34,373.04
|
| Rate for Payer: Health EOS Commercial |
$33,252.18
|
| Rate for Payer: HFN Commercial |
$34,373.04
|
| Rate for Payer: Multiplan Commercial |
$29,889.60
|
| Rate for Payer: NAPHCARE Commercial |
$22,417.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34,373.04
|
| Rate for Payer: Quartz Beloit One Network |
$18,307.38
|
| Rate for Payer: Quartz Commercial |
$22,417.20
|
| Rate for Payer: WEA Trust Commercial |
$20,549.10
|
| Rate for Payer: WPS Commercial |
$27,674.03
|
|
|
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 |
$10,461.36 |
| Max. Negotiated Rate |
$149,448.00 |
| Rate for Payer: Aetna Commercial |
$33,625.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32,131.32
|
| Rate for Payer: Aetna Managed Medicare |
$10,461.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,285.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,681.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,933.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,801.86
|
| Rate for Payer: Cash Price |
$11,208.60
|
| Rate for Payer: Cigna Commercial |
$34,373.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,907.78
|
| Rate for Payer: Health EOS Commercial |
$33,252.18
|
| Rate for Payer: HFN Commercial |
$34,373.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,021.50
|
| Rate for Payer: Multiplan Commercial |
$29,889.60
|
| Rate for Payer: NAPHCARE Commercial |
$22,417.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34,373.04
|
| Rate for Payer: Quartz Beloit One Network |
$18,307.38
|
| Rate for Payer: Quartz Commercial |
$24,285.30
|
| Rate for Payer: Quartz Medicare Advantage |
$22,417.20
|
| Rate for Payer: The Alliance Commercial |
$149,448.00
|
| Rate for Payer: WEA Trust Commercial |
$20,549.10
|
| Rate for Payer: WPS Commercial |
$27,674.03
|
|
