|
FEMUR PERSONA CR NRW SZ 9 RIGHT 42-5020-066-02
|
Facility
|
IP
|
$20,886.00
|
|
| Hospital Charge Code |
3615500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,643.51 |
| Max. Negotiated Rate |
$19,983.72 |
| Rate for Payer: Aetna Commercial |
$19,549.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,680.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,512.36
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,983.72
|
| Rate for Payer: Health EOS Commercial |
$19,332.08
|
| Rate for Payer: HFN Commercial |
$19,983.72
|
| Rate for Payer: Multiplan Commercial |
$17,377.15
|
| Rate for Payer: Preferred Network Access Commercial |
$19,983.72
|
| Rate for Payer: Quartz Beloit One Network |
$10,643.51
|
| Rate for Payer: Quartz Commercial |
$13,032.86
|
| Rate for Payer: WEA Trust Commercial |
$11,946.79
|
| Rate for Payer: WPS Commercial |
$16,088.49
|
|
|
FEMUR PERSONA CR POROUS COCR STD SZ 7 RT 42-5028-062-02
|
Facility
|
OP
|
$13,734.81
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246161
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,999.58 |
| Max. Negotiated Rate |
$13,141.47 |
| Rate for Payer: Aetna Commercial |
$12,855.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,284.41
|
| Rate for Payer: Aetna Managed Medicare |
$3,999.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,284.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,142.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,856.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,570.63
|
| Rate for Payer: Cash Price |
$4,120.44
|
| Rate for Payer: Cigna Commercial |
$13,141.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,993.66
|
| Rate for Payer: Health EOS Commercial |
$12,712.94
|
| Rate for Payer: HFN Commercial |
$13,141.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,713.15
|
| Rate for Payer: Multiplan Commercial |
$11,427.36
|
| Rate for Payer: NAPHCARE Commercial |
$8,570.52
|
| Rate for Payer: Preferred Network Access Commercial |
$13,141.47
|
| Rate for Payer: Quartz Beloit One Network |
$6,999.26
|
| Rate for Payer: Quartz Commercial |
$9,284.73
|
| Rate for Payer: Quartz Medicare Advantage |
$8,570.52
|
| Rate for Payer: The Alliance Commercial |
$7,142.10
|
| Rate for Payer: WEA Trust Commercial |
$7,856.31
|
| Rate for Payer: WPS Commercial |
$10,579.92
|
|
|
FEMUR PERSONA CR POROUS COCR STD SZ 7 RT 42-5028-062-02
|
Facility
|
IP
|
$13,734.81
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246161
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,999.26 |
| Max. Negotiated Rate |
$13,141.47 |
| Rate for Payer: Aetna Commercial |
$12,855.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,284.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,570.63
|
| Rate for Payer: Cash Price |
$4,120.44
|
| Rate for Payer: Cigna Commercial |
$13,141.47
|
| Rate for Payer: Health EOS Commercial |
$12,712.94
|
| Rate for Payer: HFN Commercial |
$13,141.47
|
| Rate for Payer: Multiplan Commercial |
$11,427.36
|
| Rate for Payer: Preferred Network Access Commercial |
$13,141.47
|
| Rate for Payer: Quartz Beloit One Network |
$6,999.26
|
| Rate for Payer: Quartz Commercial |
$8,570.52
|
| Rate for Payer: WEA Trust Commercial |
$7,856.31
|
| Rate for Payer: WPS Commercial |
$10,579.92
|
|
|
FEMUR PERSONA CR STD SZ 12 LEFT 42-5026-074-01
|
Facility
|
OP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415933
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.70 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Aetna Managed Medicare |
$4,268.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,909.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,622.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,317.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,531.54
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,434.02
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: NAPHCARE Commercial |
$9,147.22
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,909.48
|
| Rate for Payer: Quartz Medicare Advantage |
$9,147.22
|
| Rate for Payer: The Alliance Commercial |
$7,622.68
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 12 LEFT 42-5026-074-01
|
Facility
|
IP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415933
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,470.23 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,147.22
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 12 RT 42-5026-074-02
|
Facility
|
IP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520752
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,470.23 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,147.22
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 12 RT 42-5026-074-02
|
Facility
|
OP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520752
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.70 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Aetna Managed Medicare |
$4,268.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,909.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,622.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,317.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,531.54
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,434.02
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: NAPHCARE Commercial |
$9,147.22
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,909.48
|
| Rate for Payer: Quartz Medicare Advantage |
$9,147.22
|
| Rate for Payer: The Alliance Commercial |
$7,622.68
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 3 LEFT 42-5026-054-01
|
Facility
|
IP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4450335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,470.23 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,147.22
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 3 LEFT 42-5026-054-01
|
Facility
|
OP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4450335
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.70 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Aetna Managed Medicare |
$4,268.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,909.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,622.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,317.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,531.54
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,434.02
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: NAPHCARE Commercial |
$9,147.22
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,909.48
|
| Rate for Payer: Quartz Medicare Advantage |
$9,147.22
|
| Rate for Payer: The Alliance Commercial |
$7,622.68
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 4 LEFT 42-5026-056-01
|
Facility
|
IP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,470.23 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,147.22
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 4 LEFT 42-5026-056-01
|
Facility
|
OP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.70 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Aetna Managed Medicare |
$4,268.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,909.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,622.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,317.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,531.54
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,434.02
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: NAPHCARE Commercial |
$9,147.22
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,909.48
|
| Rate for Payer: Quartz Medicare Advantage |
$9,147.22
|
| Rate for Payer: The Alliance Commercial |
$7,622.68
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 5 LEFT 42-5026-058-01
|
Facility
|
IP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,470.23 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,147.22
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 5 LEFT 42-5026-058-01
|
Facility
|
OP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.70 |
| Max. Negotiated Rate |
$14,025.73 |
| Rate for Payer: Aetna Commercial |
$13,720.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,111.01
|
| Rate for Payer: Aetna Managed Medicare |
$4,268.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,909.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,622.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,317.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,080.04
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$14,025.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,531.54
|
| Rate for Payer: Health EOS Commercial |
$13,568.37
|
| Rate for Payer: HFN Commercial |
$14,025.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,434.02
|
| Rate for Payer: Multiplan Commercial |
$12,196.29
|
| Rate for Payer: NAPHCARE Commercial |
$9,147.22
|
| Rate for Payer: Preferred Network Access Commercial |
$14,025.73
|
| Rate for Payer: Quartz Beloit One Network |
$7,470.23
|
| Rate for Payer: Quartz Commercial |
$9,909.48
|
| Rate for Payer: Quartz Medicare Advantage |
$9,147.22
|
| Rate for Payer: The Alliance Commercial |
$7,622.68
|
| Rate for Payer: WEA Trust Commercial |
$8,384.95
|
| Rate for Payer: WPS Commercial |
$11,291.83
|
|
|
FEMUR PERSONA CR STD SZ 6 LT 42-5026-060-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4301879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,052.71 |
| Max. Negotiated Rate |
$20,752.04 |
| Rate for Payer: Aetna Commercial |
$20,300.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,398.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,954.98
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$20,752.04
|
| Rate for Payer: Health EOS Commercial |
$20,075.34
|
| Rate for Payer: HFN Commercial |
$20,752.04
|
| Rate for Payer: Multiplan Commercial |
$18,045.25
|
| Rate for Payer: Preferred Network Access Commercial |
$20,752.04
|
| Rate for Payer: Quartz Beloit One Network |
$11,052.71
|
| Rate for Payer: Quartz Commercial |
$13,533.94
|
| Rate for Payer: WEA Trust Commercial |
$12,406.11
|
| Rate for Payer: WPS Commercial |
$16,707.04
|
|
|
FEMUR PERSONA CR STD SZ 6 LT 42-5026-060-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4301879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,315.84 |
| Max. Negotiated Rate |
$20,752.04 |
| Rate for Payer: Aetna Commercial |
$20,300.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,398.64
|
| Rate for Payer: Aetna Managed Medicare |
$6,315.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,661.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,278.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,827.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,954.98
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$20,752.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,623.00
|
| Rate for Payer: Health EOS Commercial |
$20,075.34
|
| Rate for Payer: HFN Commercial |
$20,752.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,917.42
|
| Rate for Payer: Multiplan Commercial |
$18,045.25
|
| Rate for Payer: NAPHCARE Commercial |
$13,533.94
|
| Rate for Payer: Preferred Network Access Commercial |
$20,752.04
|
| Rate for Payer: Quartz Beloit One Network |
$11,052.71
|
| Rate for Payer: Quartz Commercial |
$14,661.76
|
| Rate for Payer: Quartz Medicare Advantage |
$13,533.94
|
| Rate for Payer: The Alliance Commercial |
$11,278.28
|
| Rate for Payer: WEA Trust Commercial |
$12,406.11
|
| Rate for Payer: WPS Commercial |
$16,707.04
|
|
|
FEMUR PERSONA CR STD SZ 6 RIGHT 42-5026-060-02
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,082.00 |
| Max. Negotiated Rate |
$19,983.72 |
| Rate for Payer: Aetna Commercial |
$19,549.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,680.44
|
| Rate for Payer: Aetna Managed Medicare |
$6,082.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,118.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,860.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,426.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,512.36
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,983.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,155.65
|
| Rate for Payer: Health EOS Commercial |
$19,332.08
|
| Rate for Payer: HFN Commercial |
$19,983.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,291.08
|
| Rate for Payer: Multiplan Commercial |
$17,377.15
|
| Rate for Payer: NAPHCARE Commercial |
$13,032.86
|
| Rate for Payer: Preferred Network Access Commercial |
$19,983.72
|
| Rate for Payer: Quartz Beloit One Network |
$10,643.51
|
| Rate for Payer: Quartz Commercial |
$14,118.94
|
| Rate for Payer: Quartz Medicare Advantage |
$13,032.86
|
| Rate for Payer: The Alliance Commercial |
$10,860.72
|
| Rate for Payer: WEA Trust Commercial |
$11,946.79
|
| Rate for Payer: WPS Commercial |
$16,088.49
|
|
|
FEMUR PERSONA CR STD SZ 6 RIGHT 42-5026-060-02
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,643.51 |
| Max. Negotiated Rate |
$19,983.72 |
| Rate for Payer: Aetna Commercial |
$19,549.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,680.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,512.36
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,983.72
|
| Rate for Payer: Health EOS Commercial |
$19,332.08
|
| Rate for Payer: HFN Commercial |
$19,983.72
|
| Rate for Payer: Multiplan Commercial |
$17,377.15
|
| Rate for Payer: Preferred Network Access Commercial |
$19,983.72
|
| Rate for Payer: Quartz Beloit One Network |
$10,643.51
|
| Rate for Payer: Quartz Commercial |
$13,032.86
|
| Rate for Payer: WEA Trust Commercial |
$11,946.79
|
| Rate for Payer: WPS Commercial |
$16,088.49
|
|
|
FEMUR PERSONA CR STD SZ 8 LEFT 42-5026-064-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,315.84 |
| Max. Negotiated Rate |
$20,752.04 |
| Rate for Payer: Aetna Commercial |
$20,300.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,398.64
|
| Rate for Payer: Aetna Managed Medicare |
$6,315.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,661.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,278.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,827.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,954.98
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$20,752.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,623.00
|
| Rate for Payer: Health EOS Commercial |
$20,075.34
|
| Rate for Payer: HFN Commercial |
$20,752.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,917.42
|
| Rate for Payer: Multiplan Commercial |
$18,045.25
|
| Rate for Payer: NAPHCARE Commercial |
$13,533.94
|
| Rate for Payer: Preferred Network Access Commercial |
$20,752.04
|
| Rate for Payer: Quartz Beloit One Network |
$11,052.71
|
| Rate for Payer: Quartz Commercial |
$14,661.76
|
| Rate for Payer: Quartz Medicare Advantage |
$13,533.94
|
| Rate for Payer: The Alliance Commercial |
$11,278.28
|
| Rate for Payer: WEA Trust Commercial |
$12,406.11
|
| Rate for Payer: WPS Commercial |
$16,707.04
|
|
|
FEMUR PERSONA CR STD SZ 8 LEFT 42-5026-064-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,052.71 |
| Max. Negotiated Rate |
$20,752.04 |
| Rate for Payer: Aetna Commercial |
$20,300.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,398.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,954.98
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$20,752.04
|
| Rate for Payer: Health EOS Commercial |
$20,075.34
|
| Rate for Payer: HFN Commercial |
$20,752.04
|
| Rate for Payer: Multiplan Commercial |
$18,045.25
|
| Rate for Payer: Preferred Network Access Commercial |
$20,752.04
|
| Rate for Payer: Quartz Beloit One Network |
$11,052.71
|
| Rate for Payer: Quartz Commercial |
$13,533.94
|
| Rate for Payer: WEA Trust Commercial |
$12,406.11
|
| Rate for Payer: WPS Commercial |
$16,707.04
|
|
|
FEMUR PERSONA CR STD SZ 8 RIGHT 42-5026-064-02
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,643.51 |
| Max. Negotiated Rate |
$19,983.72 |
| Rate for Payer: Aetna Commercial |
$19,549.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,680.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,512.36
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,983.72
|
| Rate for Payer: Health EOS Commercial |
$19,332.08
|
| Rate for Payer: HFN Commercial |
$19,983.72
|
| Rate for Payer: Multiplan Commercial |
$17,377.15
|
| Rate for Payer: Preferred Network Access Commercial |
$19,983.72
|
| Rate for Payer: Quartz Beloit One Network |
$10,643.51
|
| Rate for Payer: Quartz Commercial |
$13,032.86
|
| Rate for Payer: WEA Trust Commercial |
$11,946.79
|
| Rate for Payer: WPS Commercial |
$16,088.49
|
|
|
FEMUR PERSONA CR STD SZ 8 RIGHT 42-5026-064-02
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,082.00 |
| Max. Negotiated Rate |
$19,983.72 |
| Rate for Payer: Aetna Commercial |
$19,549.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,680.44
|
| Rate for Payer: Aetna Managed Medicare |
$6,082.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,118.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,860.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,426.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,512.36
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,983.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,155.65
|
| Rate for Payer: Health EOS Commercial |
$19,332.08
|
| Rate for Payer: HFN Commercial |
$19,983.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,291.08
|
| Rate for Payer: Multiplan Commercial |
$17,377.15
|
| Rate for Payer: NAPHCARE Commercial |
$13,032.86
|
| Rate for Payer: Preferred Network Access Commercial |
$19,983.72
|
| Rate for Payer: Quartz Beloit One Network |
$10,643.51
|
| Rate for Payer: Quartz Commercial |
$14,118.94
|
| Rate for Payer: Quartz Medicare Advantage |
$13,032.86
|
| Rate for Payer: The Alliance Commercial |
$10,860.72
|
| Rate for Payer: WEA Trust Commercial |
$11,946.79
|
| Rate for Payer: WPS Commercial |
$16,088.49
|
|
|
FEMUR PERSONA CR STD SZ 9 LEFT 42-5026-066-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4202657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,052.71 |
| Max. Negotiated Rate |
$20,752.04 |
| Rate for Payer: Aetna Commercial |
$20,300.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,398.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,954.98
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$20,752.04
|
| Rate for Payer: Health EOS Commercial |
$20,075.34
|
| Rate for Payer: HFN Commercial |
$20,752.04
|
| Rate for Payer: Multiplan Commercial |
$18,045.25
|
| Rate for Payer: Preferred Network Access Commercial |
$20,752.04
|
| Rate for Payer: Quartz Beloit One Network |
$11,052.71
|
| Rate for Payer: Quartz Commercial |
$13,533.94
|
| Rate for Payer: WEA Trust Commercial |
$12,406.11
|
| Rate for Payer: WPS Commercial |
$16,707.04
|
|
|
FEMUR PERSONA CR STD SZ 9 LEFT 42-5026-066-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4202657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,315.84 |
| Max. Negotiated Rate |
$20,752.04 |
| Rate for Payer: Aetna Commercial |
$20,300.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,398.64
|
| Rate for Payer: Aetna Managed Medicare |
$6,315.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,661.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,278.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,827.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,954.98
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$20,752.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,623.00
|
| Rate for Payer: Health EOS Commercial |
$20,075.34
|
| Rate for Payer: HFN Commercial |
$20,752.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,917.42
|
| Rate for Payer: Multiplan Commercial |
$18,045.25
|
| Rate for Payer: NAPHCARE Commercial |
$13,533.94
|
| Rate for Payer: Preferred Network Access Commercial |
$20,752.04
|
| Rate for Payer: Quartz Beloit One Network |
$11,052.71
|
| Rate for Payer: Quartz Commercial |
$14,661.76
|
| Rate for Payer: Quartz Medicare Advantage |
$13,533.94
|
| Rate for Payer: The Alliance Commercial |
$11,278.28
|
| Rate for Payer: WEA Trust Commercial |
$12,406.11
|
| Rate for Payer: WPS Commercial |
$16,707.04
|
|
|
FEMUR PERSONA CR STD SZ 9 RIGHT 42-5026-066-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4520080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,315.84 |
| Max. Negotiated Rate |
$20,752.04 |
| Rate for Payer: Aetna Commercial |
$20,300.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,398.64
|
| Rate for Payer: Aetna Managed Medicare |
$6,315.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,661.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,278.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,827.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,954.98
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$20,752.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,623.00
|
| Rate for Payer: Health EOS Commercial |
$20,075.34
|
| Rate for Payer: HFN Commercial |
$20,752.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,917.42
|
| Rate for Payer: Multiplan Commercial |
$18,045.25
|
| Rate for Payer: NAPHCARE Commercial |
$13,533.94
|
| Rate for Payer: Preferred Network Access Commercial |
$20,752.04
|
| Rate for Payer: Quartz Beloit One Network |
$11,052.71
|
| Rate for Payer: Quartz Commercial |
$14,661.76
|
| Rate for Payer: Quartz Medicare Advantage |
$13,533.94
|
| Rate for Payer: The Alliance Commercial |
$11,278.28
|
| Rate for Payer: WEA Trust Commercial |
$12,406.11
|
| Rate for Payer: WPS Commercial |
$16,707.04
|
|
|
FEMUR PERSONA CR STD SZ 9 RIGHT 42-5026-066-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4520080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,052.71 |
| Max. Negotiated Rate |
$20,752.04 |
| Rate for Payer: Aetna Commercial |
$20,300.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,398.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,954.98
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$20,752.04
|
| Rate for Payer: Health EOS Commercial |
$20,075.34
|
| Rate for Payer: HFN Commercial |
$20,752.04
|
| Rate for Payer: Multiplan Commercial |
$18,045.25
|
| Rate for Payer: Preferred Network Access Commercial |
$20,752.04
|
| Rate for Payer: Quartz Beloit One Network |
$11,052.71
|
| Rate for Payer: Quartz Commercial |
$13,533.94
|
| Rate for Payer: WEA Trust Commercial |
$12,406.11
|
| Rate for Payer: WPS Commercial |
$16,707.04
|
|
