|
FEMUR PSN PS CMT CCR STD RT SZ 11 42-5006-070-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3110204
|
|
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 12 42-5006-074-02
|
Facility
|
OP
|
$8,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,496.75 |
| Max. Negotiated Rate |
$8,203.60 |
| Rate for Payer: Aetna Commercial |
$8,025.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,668.59
|
| Rate for Payer: Aetna Managed Medicare |
$2,496.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,796.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,458.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,280.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,725.99
|
| Rate for Payer: Cash Price |
$2,572.20
|
| Rate for Payer: Cigna Commercial |
$8,203.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,990.07
|
| Rate for Payer: Health EOS Commercial |
$7,936.09
|
| Rate for Payer: HFN Commercial |
$8,203.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,687.72
|
| Rate for Payer: Multiplan Commercial |
$7,133.57
|
| Rate for Payer: NAPHCARE Commercial |
$5,350.18
|
| Rate for Payer: Preferred Network Access Commercial |
$8,203.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,369.31
|
| Rate for Payer: Quartz Commercial |
$5,796.02
|
| Rate for Payer: Quartz Medicare Advantage |
$5,350.18
|
| Rate for Payer: The Alliance Commercial |
$4,458.48
|
| Rate for Payer: WEA Trust Commercial |
$4,904.33
|
| Rate for Payer: WPS Commercial |
$6,604.55
|
|
|
FEMUR PSN PS CMT CCR STD RT SZ 12 42-5006-074-02
|
Facility
|
IP
|
$8,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,369.31 |
| Max. Negotiated Rate |
$8,203.60 |
| Rate for Payer: Aetna Commercial |
$8,025.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,668.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,725.99
|
| Rate for Payer: Cash Price |
$2,572.20
|
| Rate for Payer: Cigna Commercial |
$8,203.60
|
| Rate for Payer: Health EOS Commercial |
$7,936.09
|
| Rate for Payer: HFN Commercial |
$8,203.60
|
| Rate for Payer: Multiplan Commercial |
$7,133.57
|
| Rate for Payer: Preferred Network Access Commercial |
$8,203.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,369.31
|
| Rate for Payer: Quartz Commercial |
$5,350.18
|
| Rate for Payer: WEA Trust Commercial |
$4,904.33
|
| Rate for Payer: WPS Commercial |
$6,604.55
|
|
|
FEMUR PSN PS CMT CCR STD RT SZ 5 42-5006-058-02
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950687
|
|
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 RT SZ 5 42-5006-058-02
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950687
|
|
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 RT SZ 6 42-5006-060-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950689
|
|
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 6 42-5006-060-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950689
|
|
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 7 42-5006-062-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3285464
|
|
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 7 42-5006-062-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3285464
|
|
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 8 42-5006-064-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615495
|
|
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 8 42-5006-064-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615495
|
|
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 9 42-5006-066-02
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177469
|
|
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 RT SZ 9 42-5006-066-02
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177469
|
|
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, TENDON & NERVE REPAIR
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2960418
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,214.30 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,214.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,818.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,168.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,081.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,426.94
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,252.60
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,602.08
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,818.92
|
| Rate for Payer: Quartz Medicare Advantage |
$2,602.08
|
| Rate for Payer: The Alliance Commercial |
$2,168.40
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
FEMUR, TENDON & NERVE REPAIR
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2960418
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,125.03 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,602.08
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
FEMUR TRIATHLON CR SZ 2 LT 5510-F-201
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,373.84 |
| Max. Negotiated Rate |
$11,085.48 |
| Rate for Payer: Aetna Commercial |
$10,844.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,362.52
|
| Rate for Payer: Aetna Managed Medicare |
$3,373.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,832.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,024.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,783.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,386.20
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$11,085.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,743.05
|
| Rate for Payer: Health EOS Commercial |
$10,724.00
|
| Rate for Payer: HFN Commercial |
$11,085.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,037.08
|
| Rate for Payer: Multiplan Commercial |
$9,639.55
|
| Rate for Payer: NAPHCARE Commercial |
$7,229.66
|
| Rate for Payer: Preferred Network Access Commercial |
$11,085.48
|
| Rate for Payer: Quartz Beloit One Network |
$5,904.23
|
| Rate for Payer: Quartz Commercial |
$7,832.14
|
| Rate for Payer: Quartz Medicare Advantage |
$7,229.66
|
| Rate for Payer: The Alliance Commercial |
$6,024.72
|
| Rate for Payer: WEA Trust Commercial |
$6,627.19
|
| Rate for Payer: WPS Commercial |
$8,924.70
|
|
|
FEMUR TRIATHLON CR SZ 2 LT 5510-F-201
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,904.23 |
| Max. Negotiated Rate |
$11,085.48 |
| Rate for Payer: Aetna Commercial |
$10,844.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,362.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,386.20
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$11,085.48
|
| Rate for Payer: Health EOS Commercial |
$10,724.00
|
| Rate for Payer: HFN Commercial |
$11,085.48
|
| Rate for Payer: Multiplan Commercial |
$9,639.55
|
| Rate for Payer: Preferred Network Access Commercial |
$11,085.48
|
| Rate for Payer: Quartz Beloit One Network |
$5,904.23
|
| Rate for Payer: Quartz Commercial |
$7,229.66
|
| Rate for Payer: WEA Trust Commercial |
$6,627.19
|
| Rate for Payer: WPS Commercial |
$8,924.70
|
|
|
FEMUR TRIATHLON CR SZ 2 LT 5517-F-201
|
Facility
|
IP
|
$19,515.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4343565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,944.84 |
| Max. Negotiated Rate |
$18,671.95 |
| Rate for Payer: Aetna Commercial |
$18,266.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,454.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,756.67
|
| Rate for Payer: Cash Price |
$5,854.50
|
| Rate for Payer: Cigna Commercial |
$18,671.95
|
| Rate for Payer: Health EOS Commercial |
$18,063.08
|
| Rate for Payer: HFN Commercial |
$18,671.95
|
| Rate for Payer: Multiplan Commercial |
$16,236.48
|
| Rate for Payer: Preferred Network Access Commercial |
$18,671.95
|
| Rate for Payer: Quartz Beloit One Network |
$9,944.84
|
| Rate for Payer: Quartz Commercial |
$12,177.36
|
| Rate for Payer: WEA Trust Commercial |
$11,162.58
|
| Rate for Payer: WPS Commercial |
$15,032.40
|
|
|
FEMUR TRIATHLON CR SZ 2 LT 5517-F-201
|
Facility
|
OP
|
$19,515.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4343565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,682.77 |
| Max. Negotiated Rate |
$18,671.95 |
| Rate for Payer: Aetna Commercial |
$18,266.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,454.22
|
| Rate for Payer: Aetna Managed Medicare |
$5,682.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,192.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,147.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,741.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,756.67
|
| Rate for Payer: Cash Price |
$5,854.50
|
| Rate for Payer: Cigna Commercial |
$18,671.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,357.73
|
| Rate for Payer: Health EOS Commercial |
$18,063.08
|
| Rate for Payer: HFN Commercial |
$18,671.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,221.70
|
| Rate for Payer: Multiplan Commercial |
$16,236.48
|
| Rate for Payer: NAPHCARE Commercial |
$12,177.36
|
| Rate for Payer: Preferred Network Access Commercial |
$18,671.95
|
| Rate for Payer: Quartz Beloit One Network |
$9,944.84
|
| Rate for Payer: Quartz Commercial |
$13,192.14
|
| Rate for Payer: Quartz Medicare Advantage |
$12,177.36
|
| Rate for Payer: The Alliance Commercial |
$10,147.80
|
| Rate for Payer: WEA Trust Commercial |
$11,162.58
|
| Rate for Payer: WPS Commercial |
$15,032.40
|
|
|
FEMUR TRIATHLON CR SZ 2 RT 5517-F-202
|
Facility
|
IP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,326.53 |
| Max. Negotiated Rate |
$19,388.60 |
| Rate for Payer: Aetna Commercial |
$18,967.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,124.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,169.52
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$19,388.60
|
| Rate for Payer: Health EOS Commercial |
$18,756.36
|
| Rate for Payer: HFN Commercial |
$19,388.60
|
| Rate for Payer: Multiplan Commercial |
$16,859.65
|
| Rate for Payer: Preferred Network Access Commercial |
$19,388.60
|
| Rate for Payer: Quartz Beloit One Network |
$10,326.53
|
| Rate for Payer: Quartz Commercial |
$12,644.74
|
| Rate for Payer: WEA Trust Commercial |
$11,591.01
|
| Rate for Payer: WPS Commercial |
$15,609.36
|
|
|
FEMUR TRIATHLON CR SZ 2 RT 5517-F-202
|
Facility
|
OP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,900.88 |
| Max. Negotiated Rate |
$19,388.60 |
| Rate for Payer: Aetna Commercial |
$18,967.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,124.12
|
| Rate for Payer: Aetna Managed Medicare |
$5,900.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,698.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,537.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,115.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,169.52
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$19,388.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,793.65
|
| Rate for Payer: Health EOS Commercial |
$18,756.36
|
| Rate for Payer: HFN Commercial |
$19,388.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,805.92
|
| Rate for Payer: Multiplan Commercial |
$16,859.65
|
| Rate for Payer: NAPHCARE Commercial |
$12,644.74
|
| Rate for Payer: Preferred Network Access Commercial |
$19,388.60
|
| Rate for Payer: Quartz Beloit One Network |
$10,326.53
|
| Rate for Payer: Quartz Commercial |
$13,698.46
|
| Rate for Payer: Quartz Medicare Advantage |
$12,644.74
|
| Rate for Payer: The Alliance Commercial |
$10,537.28
|
| Rate for Payer: WEA Trust Commercial |
$11,591.01
|
| Rate for Payer: WPS Commercial |
$15,609.36
|
|
|
FEMUR TRIATHLON CR SZ 3 LT 5510-F-301
|
Facility
|
OP
|
$11,591.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3072401
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,375.30 |
| Max. Negotiated Rate |
$11,090.27 |
| Rate for Payer: Aetna Commercial |
$10,849.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,366.99
|
| Rate for Payer: Aetna Managed Medicare |
$3,375.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,835.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,027.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,786.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,388.96
|
| Rate for Payer: Cash Price |
$3,477.30
|
| Rate for Payer: Cigna Commercial |
$11,090.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,745.96
|
| Rate for Payer: Health EOS Commercial |
$10,728.63
|
| Rate for Payer: HFN Commercial |
$11,090.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,040.98
|
| Rate for Payer: Multiplan Commercial |
$9,643.71
|
| Rate for Payer: NAPHCARE Commercial |
$7,232.78
|
| Rate for Payer: Preferred Network Access Commercial |
$11,090.27
|
| Rate for Payer: Quartz Beloit One Network |
$5,906.77
|
| Rate for Payer: Quartz Commercial |
$7,835.52
|
| Rate for Payer: Quartz Medicare Advantage |
$7,232.78
|
| Rate for Payer: The Alliance Commercial |
$6,027.32
|
| Rate for Payer: WEA Trust Commercial |
$6,630.05
|
| Rate for Payer: WPS Commercial |
$8,928.55
|
|
|
FEMUR TRIATHLON CR SZ 3 LT 5510-F-301
|
Facility
|
IP
|
$11,591.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3072401
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,906.77 |
| Max. Negotiated Rate |
$11,090.27 |
| Rate for Payer: Aetna Commercial |
$10,849.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,366.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,388.96
|
| Rate for Payer: Cash Price |
$3,477.30
|
| Rate for Payer: Cigna Commercial |
$11,090.27
|
| Rate for Payer: Health EOS Commercial |
$10,728.63
|
| Rate for Payer: HFN Commercial |
$11,090.27
|
| Rate for Payer: Multiplan Commercial |
$9,643.71
|
| Rate for Payer: Preferred Network Access Commercial |
$11,090.27
|
| Rate for Payer: Quartz Beloit One Network |
$5,906.77
|
| Rate for Payer: Quartz Commercial |
$7,232.78
|
| Rate for Payer: WEA Trust Commercial |
$6,630.05
|
| Rate for Payer: WPS Commercial |
$8,928.55
|
|
|
FEMUR TRIATHLON CR SZ 3 LT 5517-F-301
|
Facility
|
IP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779539
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,326.53 |
| Max. Negotiated Rate |
$19,388.60 |
| Rate for Payer: Aetna Commercial |
$18,967.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,124.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,169.52
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$19,388.60
|
| Rate for Payer: Health EOS Commercial |
$18,756.36
|
| Rate for Payer: HFN Commercial |
$19,388.60
|
| Rate for Payer: Multiplan Commercial |
$16,859.65
|
| Rate for Payer: Preferred Network Access Commercial |
$19,388.60
|
| Rate for Payer: Quartz Beloit One Network |
$10,326.53
|
| Rate for Payer: Quartz Commercial |
$12,644.74
|
| Rate for Payer: WEA Trust Commercial |
$11,591.01
|
| Rate for Payer: WPS Commercial |
$15,609.36
|
|
|
FEMUR TRIATHLON CR SZ 3 LT 5517-F-301
|
Facility
|
OP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779539
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,900.88 |
| Max. Negotiated Rate |
$19,388.60 |
| Rate for Payer: Aetna Commercial |
$18,967.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,124.12
|
| Rate for Payer: Aetna Managed Medicare |
$5,900.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,698.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,537.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,115.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,169.52
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$19,388.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,793.65
|
| Rate for Payer: Health EOS Commercial |
$18,756.36
|
| Rate for Payer: HFN Commercial |
$19,388.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,805.92
|
| Rate for Payer: Multiplan Commercial |
$16,859.65
|
| Rate for Payer: NAPHCARE Commercial |
$12,644.74
|
| Rate for Payer: Preferred Network Access Commercial |
$19,388.60
|
| Rate for Payer: Quartz Beloit One Network |
$10,326.53
|
| Rate for Payer: Quartz Commercial |
$13,698.46
|
| Rate for Payer: Quartz Medicare Advantage |
$12,644.74
|
| Rate for Payer: The Alliance Commercial |
$10,537.28
|
| Rate for Payer: WEA Trust Commercial |
$11,591.01
|
| Rate for Payer: WPS Commercial |
$15,609.36
|
|
