|
FEMUR PERSONA CR CMT NRW SZ 5 RT 42-5020-058-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4400975
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,627.61 |
| Max. Negotiated Rate |
$19,953.88 |
| Rate for Payer: Aetna Commercial |
$19,520.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,652.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,495.17
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$19,953.88
|
| Rate for Payer: Health EOS Commercial |
$19,303.21
|
| Rate for Payer: HFN Commercial |
$19,953.88
|
| Rate for Payer: Multiplan Commercial |
$17,351.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,013.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,953.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,627.61
|
| Rate for Payer: Quartz Commercial |
$13,013.40
|
| Rate for Payer: WEA Trust Commercial |
$11,928.95
|
| Rate for Payer: WPS Commercial |
$16,065.04
|
|
|
FEMUR PERSONA CR CMT NRW SZ 5 RT 42-5020-058-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4400975
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| Max. Negotiated Rate |
$86,756.00 |
| Rate for Payer: Aetna Commercial |
$19,520.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,652.54
|
| Rate for Payer: Aetna Managed Medicare |
$6,072.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,097.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,844.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,410.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,495.17
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$19,953.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,137.16
|
| Rate for Payer: Health EOS Commercial |
$19,303.21
|
| Rate for Payer: HFN Commercial |
$19,953.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,266.75
|
| Rate for Payer: Multiplan Commercial |
$17,351.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,013.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,953.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,627.61
|
| Rate for Payer: Quartz Commercial |
$14,097.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13,013.40
|
| Rate for Payer: The Alliance Commercial |
$86,756.00
|
| Rate for Payer: WEA Trust Commercial |
$11,928.95
|
| Rate for Payer: WPS Commercial |
$16,065.04
|
|
|
FEMUR PERSONA CR NARROW SZ 5 LEFT 42-5020-058-01
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4220556
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| Max. Negotiated Rate |
$19,215.12 |
| Rate for Payer: Aetna Commercial |
$18,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,961.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,069.58
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,215.12
|
| Rate for Payer: Health EOS Commercial |
$18,588.54
|
| Rate for Payer: HFN Commercial |
$19,215.12
|
| Rate for Payer: Multiplan Commercial |
$16,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,531.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,215.12
|
| Rate for Payer: Quartz Beloit One Network |
$10,234.14
|
| Rate for Payer: Quartz Commercial |
$12,531.60
|
| Rate for Payer: WEA Trust Commercial |
$11,487.30
|
| Rate for Payer: WPS Commercial |
$15,470.26
|
|
|
FEMUR PERSONA CR NARROW SZ 5 LEFT 42-5020-058-01
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4220556
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,848.08 |
| Max. Negotiated Rate |
$83,544.00 |
| Rate for Payer: Aetna Commercial |
$18,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,961.96
|
| Rate for Payer: Aetna Managed Medicare |
$5,848.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,575.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,443.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,025.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,069.58
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,215.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,687.81
|
| Rate for Payer: Health EOS Commercial |
$18,588.54
|
| Rate for Payer: HFN Commercial |
$19,215.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,664.50
|
| Rate for Payer: Multiplan Commercial |
$16,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,531.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,215.12
|
| Rate for Payer: Quartz Beloit One Network |
$10,234.14
|
| Rate for Payer: Quartz Commercial |
$13,575.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12,531.60
|
| Rate for Payer: The Alliance Commercial |
$83,544.00
|
| Rate for Payer: WEA Trust Commercial |
$11,487.30
|
| Rate for Payer: WPS Commercial |
$15,470.26
|
|
|
FEMUR PERSONA CR NRW SZ 11 LT 42-5020-070-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4520102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| Max. Negotiated Rate |
$86,756.00 |
| Rate for Payer: Aetna Commercial |
$19,520.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,652.54
|
| Rate for Payer: Aetna Managed Medicare |
$6,072.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,097.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,844.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,410.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,495.17
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$19,953.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,137.16
|
| Rate for Payer: Health EOS Commercial |
$19,303.21
|
| Rate for Payer: HFN Commercial |
$19,953.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,266.75
|
| Rate for Payer: Multiplan Commercial |
$17,351.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,013.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,953.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,627.61
|
| Rate for Payer: Quartz Commercial |
$14,097.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13,013.40
|
| Rate for Payer: The Alliance Commercial |
$86,756.00
|
| Rate for Payer: WEA Trust Commercial |
$11,928.95
|
| Rate for Payer: WPS Commercial |
$16,065.04
|
|
|
FEMUR PERSONA CR NRW SZ 11 LT 42-5020-070-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4520102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,627.61 |
| Max. Negotiated Rate |
$19,953.88 |
| Rate for Payer: Aetna Commercial |
$19,520.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,652.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,495.17
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$19,953.88
|
| Rate for Payer: Health EOS Commercial |
$19,303.21
|
| Rate for Payer: HFN Commercial |
$19,953.88
|
| Rate for Payer: Multiplan Commercial |
$17,351.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,013.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,953.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,627.61
|
| Rate for Payer: Quartz Commercial |
$13,013.40
|
| Rate for Payer: WEA Trust Commercial |
$11,928.95
|
| Rate for Payer: WPS Commercial |
$16,065.04
|
|
|
FEMUR PERSONA CR NRW SZ 11 RT 42-5020-070-02
|
Facility
|
OP
|
$21,689.00
|
|
| Hospital Charge Code |
4518702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| Max. Negotiated Rate |
$86,756.00 |
| Rate for Payer: Aetna Commercial |
$19,520.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,652.54
|
| Rate for Payer: Aetna Managed Medicare |
$6,072.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,097.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,844.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,410.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,495.17
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$19,953.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,137.16
|
| Rate for Payer: Health EOS Commercial |
$19,303.21
|
| Rate for Payer: HFN Commercial |
$19,953.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,266.75
|
| Rate for Payer: Multiplan Commercial |
$17,351.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,013.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,953.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,627.61
|
| Rate for Payer: Quartz Commercial |
$14,097.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13,013.40
|
| Rate for Payer: The Alliance Commercial |
$86,756.00
|
| Rate for Payer: WEA Trust Commercial |
$11,928.95
|
| Rate for Payer: WPS Commercial |
$16,065.04
|
|
|
FEMUR PERSONA CR NRW SZ 11 RT 42-5020-070-02
|
Facility
|
IP
|
$21,689.00
|
|
| Hospital Charge Code |
4518702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,627.61 |
| Max. Negotiated Rate |
$19,953.88 |
| Rate for Payer: Aetna Commercial |
$19,520.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,652.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,495.17
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$19,953.88
|
| Rate for Payer: Health EOS Commercial |
$19,303.21
|
| Rate for Payer: HFN Commercial |
$19,953.88
|
| Rate for Payer: Multiplan Commercial |
$17,351.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,013.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,953.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,627.61
|
| Rate for Payer: Quartz Commercial |
$13,013.40
|
| Rate for Payer: WEA Trust Commercial |
$11,928.95
|
| Rate for Payer: WPS Commercial |
$16,065.04
|
|
|
FEMUR PERSONA CR NRW SZ 7 LEFT 42-5020-062-01
|
Facility
|
OP
|
$20,886.00
|
|
| Hospital Charge Code |
3721494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,848.08 |
| Max. Negotiated Rate |
$83,544.00 |
| Rate for Payer: Aetna Commercial |
$18,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,961.96
|
| Rate for Payer: Aetna Managed Medicare |
$5,848.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,575.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,443.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,025.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,069.58
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,215.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,687.81
|
| Rate for Payer: Health EOS Commercial |
$18,588.54
|
| Rate for Payer: HFN Commercial |
$19,215.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,664.50
|
| Rate for Payer: Multiplan Commercial |
$16,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,531.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,215.12
|
| Rate for Payer: Quartz Beloit One Network |
$10,234.14
|
| Rate for Payer: Quartz Commercial |
$13,575.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12,531.60
|
| Rate for Payer: The Alliance Commercial |
$83,544.00
|
| Rate for Payer: WEA Trust Commercial |
$11,487.30
|
| Rate for Payer: WPS Commercial |
$15,470.26
|
|
|
FEMUR PERSONA CR NRW SZ 7 LEFT 42-5020-062-01
|
Facility
|
IP
|
$20,886.00
|
|
| Hospital Charge Code |
3721494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| Max. Negotiated Rate |
$19,215.12 |
| Rate for Payer: Aetna Commercial |
$18,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,961.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,069.58
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,215.12
|
| Rate for Payer: Health EOS Commercial |
$18,588.54
|
| Rate for Payer: HFN Commercial |
$19,215.12
|
| Rate for Payer: Multiplan Commercial |
$16,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,531.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,215.12
|
| Rate for Payer: Quartz Beloit One Network |
$10,234.14
|
| Rate for Payer: Quartz Commercial |
$12,531.60
|
| Rate for Payer: WEA Trust Commercial |
$11,487.30
|
| Rate for Payer: WPS Commercial |
$15,470.26
|
|
|
FEMUR PERSONA CR NRW SZ 9 LEFT 42-5020-066-01
|
Facility
|
OP
|
$21,689.00
|
|
| Hospital Charge Code |
4494112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| Max. Negotiated Rate |
$86,756.00 |
| Rate for Payer: Aetna Commercial |
$19,520.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,652.54
|
| Rate for Payer: Aetna Managed Medicare |
$6,072.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,097.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,844.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,410.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,495.17
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$19,953.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,137.16
|
| Rate for Payer: Health EOS Commercial |
$19,303.21
|
| Rate for Payer: HFN Commercial |
$19,953.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,266.75
|
| Rate for Payer: Multiplan Commercial |
$17,351.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,013.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,953.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,627.61
|
| Rate for Payer: Quartz Commercial |
$14,097.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13,013.40
|
| Rate for Payer: The Alliance Commercial |
$86,756.00
|
| Rate for Payer: WEA Trust Commercial |
$11,928.95
|
| Rate for Payer: WPS Commercial |
$16,065.04
|
|
|
FEMUR PERSONA CR NRW SZ 9 LEFT 42-5020-066-01
|
Facility
|
IP
|
$21,689.00
|
|
| Hospital Charge Code |
4494112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,627.61 |
| Max. Negotiated Rate |
$19,953.88 |
| Rate for Payer: Aetna Commercial |
$19,520.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,652.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,495.17
|
| Rate for Payer: Cash Price |
$6,506.70
|
| Rate for Payer: Cigna Commercial |
$19,953.88
|
| Rate for Payer: Health EOS Commercial |
$19,303.21
|
| Rate for Payer: HFN Commercial |
$19,953.88
|
| Rate for Payer: Multiplan Commercial |
$17,351.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,013.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,953.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,627.61
|
| Rate for Payer: Quartz Commercial |
$13,013.40
|
| Rate for Payer: WEA Trust Commercial |
$11,928.95
|
| Rate for Payer: WPS Commercial |
$16,065.04
|
|
|
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 |
$10,234.14 |
| Max. Negotiated Rate |
$19,215.12 |
| Rate for Payer: Aetna Commercial |
$18,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,961.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,069.58
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,215.12
|
| Rate for Payer: Health EOS Commercial |
$18,588.54
|
| Rate for Payer: HFN Commercial |
$19,215.12
|
| Rate for Payer: Multiplan Commercial |
$16,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,531.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,215.12
|
| Rate for Payer: Quartz Beloit One Network |
$10,234.14
|
| Rate for Payer: Quartz Commercial |
$12,531.60
|
| Rate for Payer: WEA Trust Commercial |
$11,487.30
|
| Rate for Payer: WPS Commercial |
$15,470.26
|
|
|
FEMUR PERSONA CR NRW SZ 9 RIGHT 42-5020-066-02
|
Facility
|
OP
|
$20,886.00
|
|
| Hospital Charge Code |
3615500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,848.08 |
| Max. Negotiated Rate |
$83,544.00 |
| Rate for Payer: Aetna Commercial |
$18,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,961.96
|
| Rate for Payer: Aetna Managed Medicare |
$5,848.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,575.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,443.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,025.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,069.58
|
| Rate for Payer: Cash Price |
$6,265.80
|
| Rate for Payer: Cigna Commercial |
$19,215.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,687.81
|
| Rate for Payer: Health EOS Commercial |
$18,588.54
|
| Rate for Payer: HFN Commercial |
$19,215.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,664.50
|
| Rate for Payer: Multiplan Commercial |
$16,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,531.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,215.12
|
| Rate for Payer: Quartz Beloit One Network |
$10,234.14
|
| Rate for Payer: Quartz Commercial |
$13,575.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12,531.60
|
| Rate for Payer: The Alliance Commercial |
$83,544.00
|
| Rate for Payer: WEA Trust Commercial |
$11,487.30
|
| Rate for Payer: WPS Commercial |
$15,470.26
|
|
|
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 |
$6,730.06 |
| Max. Negotiated Rate |
$12,636.03 |
| Rate for Payer: Aetna Commercial |
$12,361.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,811.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,279.45
|
| Rate for Payer: Cash Price |
$4,120.44
|
| Rate for Payer: Cigna Commercial |
$12,636.03
|
| Rate for Payer: Health EOS Commercial |
$12,223.98
|
| Rate for Payer: HFN Commercial |
$12,636.03
|
| Rate for Payer: Multiplan Commercial |
$10,987.85
|
| Rate for Payer: NAPHCARE Commercial |
$8,240.89
|
| Rate for Payer: Preferred Network Access Commercial |
$12,636.03
|
| Rate for Payer: Quartz Beloit One Network |
$6,730.06
|
| Rate for Payer: Quartz Commercial |
$8,240.89
|
| Rate for Payer: WEA Trust Commercial |
$7,554.15
|
| Rate for Payer: WPS Commercial |
$10,173.37
|
|
|
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 |
$3,845.75 |
| Max. Negotiated Rate |
$54,939.24 |
| Rate for Payer: Aetna Commercial |
$12,361.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,811.94
|
| Rate for Payer: Aetna Managed Medicare |
$3,845.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,927.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,867.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,592.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,279.45
|
| Rate for Payer: Cash Price |
$4,120.44
|
| Rate for Payer: Cigna Commercial |
$12,636.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,686.00
|
| Rate for Payer: Health EOS Commercial |
$12,223.98
|
| Rate for Payer: HFN Commercial |
$12,636.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,301.11
|
| Rate for Payer: Multiplan Commercial |
$10,987.85
|
| Rate for Payer: NAPHCARE Commercial |
$8,240.89
|
| Rate for Payer: Preferred Network Access Commercial |
$12,636.03
|
| Rate for Payer: Quartz Beloit One Network |
$6,730.06
|
| Rate for Payer: Quartz Commercial |
$8,927.63
|
| Rate for Payer: Quartz Medicare Advantage |
$8,240.89
|
| Rate for Payer: The Alliance Commercial |
$54,939.24
|
| Rate for Payer: WEA Trust Commercial |
$7,554.15
|
| Rate for Payer: WPS Commercial |
$10,173.37
|
|
|
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 |
$7,182.91 |
| Max. Negotiated Rate |
$13,486.28 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$8,795.40
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
|
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 |
$4,104.52 |
| Max. Negotiated Rate |
$58,636.00 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,104.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,528.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,329.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,036.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,203.18
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,994.25
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$9,528.35
|
| Rate for Payer: Quartz Medicare Advantage |
$8,795.40
|
| Rate for Payer: The Alliance Commercial |
$58,636.00
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
|
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 |
$7,182.91 |
| Max. Negotiated Rate |
$13,486.28 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$8,795.40
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
|
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 |
$4,104.52 |
| Max. Negotiated Rate |
$58,636.00 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,104.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,528.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,329.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,036.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,203.18
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,994.25
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$9,528.35
|
| Rate for Payer: Quartz Medicare Advantage |
$8,795.40
|
| Rate for Payer: The Alliance Commercial |
$58,636.00
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
|
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 |
$4,104.52 |
| Max. Negotiated Rate |
$58,636.00 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,104.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,528.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,329.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,036.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,203.18
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,994.25
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$9,528.35
|
| Rate for Payer: Quartz Medicare Advantage |
$8,795.40
|
| Rate for Payer: The Alliance Commercial |
$58,636.00
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
|
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 |
$7,182.91 |
| Max. Negotiated Rate |
$13,486.28 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$8,795.40
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
|
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 |
$7,182.91 |
| Max. Negotiated Rate |
$13,486.28 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$8,795.40
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
|
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 |
$4,104.52 |
| Max. Negotiated Rate |
$58,636.00 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,104.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,528.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,329.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,036.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,203.18
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,994.25
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$9,528.35
|
| Rate for Payer: Quartz Medicare Advantage |
$8,795.40
|
| Rate for Payer: The Alliance Commercial |
$58,636.00
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
|
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 |
$4,104.52 |
| Max. Negotiated Rate |
$58,636.00 |
| Rate for Payer: Aetna Commercial |
$13,193.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,606.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,104.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,528.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,329.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,036.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,769.27
|
| Rate for Payer: Cash Price |
$4,397.70
|
| Rate for Payer: Cigna Commercial |
$13,486.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,203.18
|
| Rate for Payer: Health EOS Commercial |
$13,046.51
|
| Rate for Payer: HFN Commercial |
$13,486.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,994.25
|
| Rate for Payer: Multiplan Commercial |
$11,727.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,795.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,486.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,182.91
|
| Rate for Payer: Quartz Commercial |
$9,528.35
|
| Rate for Payer: Quartz Medicare Advantage |
$8,795.40
|
| Rate for Payer: The Alliance Commercial |
$58,636.00
|
| Rate for Payer: WEA Trust Commercial |
$8,062.45
|
| Rate for Payer: WPS Commercial |
$10,857.92
|
|
