|
FEMUR PSN PS CMT CCR NRW RT SZ 8 42-5000-064-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3813021
|
|
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 PSN PS CMT CCR NRW RT SZ 8 42-5000-064-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3813021
|
|
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 PSN PS CMT CCR NRW RT SZ 9 42-5000-066-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221469
|
|
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 PSN PS CMT CCR NRW RT SZ 9 42-5000-066-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221469
|
|
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 PSN PS CMT CCR STD LT SZ 10 42-5006-068-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267492
|
|
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 PSN PS CMT CCR STD LT SZ 10 42-5006-068-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267492
|
|
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 PSN PS CMT CCR STD LT SZ 11 42-5006-070-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3949328
|
|
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 PSN PS CMT CCR STD LT SZ 11 42-5006-070-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3949328
|
|
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 PSN PS CMT CCR STD LT SZ 12 42-5006-074-01
|
Facility
|
IP
|
$16,138.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5307022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,223.92 |
| Max. Negotiated Rate |
$15,440.84 |
| Rate for Payer: Aetna Commercial |
$15,105.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,433.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,895.27
|
| Rate for Payer: Cash Price |
$4,841.40
|
| Rate for Payer: Cigna Commercial |
$15,440.84
|
| Rate for Payer: Health EOS Commercial |
$14,937.33
|
| Rate for Payer: HFN Commercial |
$15,440.84
|
| Rate for Payer: Multiplan Commercial |
$13,426.82
|
| Rate for Payer: Preferred Network Access Commercial |
$15,440.84
|
| Rate for Payer: Quartz Beloit One Network |
$8,223.92
|
| Rate for Payer: Quartz Commercial |
$10,070.11
|
| Rate for Payer: WEA Trust Commercial |
$9,230.94
|
| Rate for Payer: WPS Commercial |
$12,431.10
|
|
|
FEMUR PSN PS CMT CCR STD LT SZ 12 42-5006-074-01
|
Facility
|
OP
|
$16,138.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5307022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,699.39 |
| Max. Negotiated Rate |
$15,440.84 |
| Rate for Payer: Aetna Commercial |
$15,105.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,433.83
|
| Rate for Payer: Aetna Managed Medicare |
$4,699.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,909.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,391.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,056.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,895.27
|
| Rate for Payer: Cash Price |
$4,841.40
|
| Rate for Payer: Cigna Commercial |
$15,440.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,392.32
|
| Rate for Payer: Health EOS Commercial |
$14,937.33
|
| Rate for Payer: HFN Commercial |
$15,440.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,587.64
|
| Rate for Payer: Multiplan Commercial |
$13,426.82
|
| Rate for Payer: NAPHCARE Commercial |
$10,070.11
|
| Rate for Payer: Preferred Network Access Commercial |
$15,440.84
|
| Rate for Payer: Quartz Beloit One Network |
$8,223.92
|
| Rate for Payer: Quartz Commercial |
$10,909.29
|
| Rate for Payer: Quartz Medicare Advantage |
$10,070.11
|
| Rate for Payer: The Alliance Commercial |
$8,391.76
|
| Rate for Payer: WEA Trust Commercial |
$9,230.94
|
| Rate for Payer: WPS Commercial |
$12,431.10
|
|
|
FEMUR PSN PS CMT CCR STD LT SZ 4 42-5006-056-01
|
Facility
|
OP
|
$14,095.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5307143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,104.46 |
| Max. Negotiated Rate |
$13,486.10 |
| Rate for Payer: Aetna Commercial |
$13,192.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.57
|
| Rate for Payer: Aetna Managed Medicare |
$4,104.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,528.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,329.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,036.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.16
|
| Rate for Payer: Cash Price |
$4,228.50
|
| Rate for Payer: Cigna Commercial |
$13,486.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,203.29
|
| Rate for Payer: Health EOS Commercial |
$13,046.33
|
| Rate for Payer: HFN Commercial |
$13,486.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,994.10
|
| Rate for Payer: Multiplan Commercial |
$11,727.04
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.28
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.10
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.81
|
| Rate for Payer: Quartz Commercial |
$9,528.22
|
| Rate for Payer: Quartz Medicare Advantage |
$8,795.28
|
| Rate for Payer: The Alliance Commercial |
$7,329.40
|
| Rate for Payer: WEA Trust Commercial |
$8,062.34
|
| Rate for Payer: WPS Commercial |
$10,857.38
|
|
|
FEMUR PSN PS CMT CCR STD LT SZ 4 42-5006-056-01
|
Facility
|
IP
|
$14,095.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5307143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,182.81 |
| Max. Negotiated Rate |
$13,486.10 |
| Rate for Payer: Aetna Commercial |
$13,192.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.16
|
| Rate for Payer: Cash Price |
$4,228.50
|
| Rate for Payer: Cigna Commercial |
$13,486.10
|
| Rate for Payer: Health EOS Commercial |
$13,046.33
|
| Rate for Payer: HFN Commercial |
$13,486.10
|
| Rate for Payer: Multiplan Commercial |
$11,727.04
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.10
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.81
|
| Rate for Payer: Quartz Commercial |
$8,795.28
|
| Rate for Payer: WEA Trust Commercial |
$8,062.34
|
| Rate for Payer: WPS Commercial |
$10,857.38
|
|
|
FEMUR PSN PS CMT CCR STD LT SZ 5 42-5006-058-01
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950686
|
|
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 PSN PS CMT CCR STD LT SZ 5 42-5006-058-01
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950686
|
|
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 PSN PS CMT CCR STD LT SZ 6 42-5006-060-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950688
|
|
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 PSN PS CMT CCR STD LT SZ 6 42-5006-060-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950688
|
|
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 PSN PS CMT CCR STD LT SZ 7 42-5006-062-01
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3337518
|
|
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 PSN PS CMT CCR STD LT SZ 7 42-5006-062-01
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3337518
|
|
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 PSN PS CMT CCR STD LT SZ 8 42-5006-064-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3241466
|
|
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 PSN PS CMT CCR STD LT SZ 8 42-5006-064-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3241466
|
|
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 PSN PS CMT CCR STD LT SZ 9 42-5006-066-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950691
|
|
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 PSN PS CMT CCR STD LT SZ 9 42-5006-066-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950691
|
|
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 PSN PS CMT CCR STD RT SZ 10 42-5006-068-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3827382
|
|
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 PSN PS CMT CCR STD RT SZ 10 42-5006-068-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3827382
|
|
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 PSN PS CMT CCR STD RT SZ 11 42-5006-070-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3110204
|
|
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
|
|
