|
FEMUR PERSONA CR STD SZ 5 LEFT 42-5026-058-01
|
Facility
|
IP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,182.91 |
| 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 6 LT 42-5026-060-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4301879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 STD SZ 6 LT 42-5026-060-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4301879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 STD SZ 6 RIGHT 42-5026-060-02
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 STD SZ 6 RIGHT 42-5026-060-02
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| 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 STD SZ 8 LEFT 42-5026-064-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 STD SZ 8 LEFT 42-5026-064-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 STD SZ 8 RIGHT 42-5026-064-02
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 STD SZ 8 RIGHT 42-5026-064-02
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| 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 STD SZ 9 LEFT 42-5026-066-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4202657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 STD SZ 9 LEFT 42-5026-066-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4202657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 STD SZ 9 RIGHT 42-5026-066-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4520080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 STD SZ 9 RIGHT 42-5026-066-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4520080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 SZ 4 RT 42-5020-056-02
|
Facility
|
OP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4520383
|
|
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 SZ 4 RT 42-5020-056-02
|
Facility
|
IP
|
$14,659.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4520383
|
|
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 SZ 7 RT 42-5020-062-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3491508
|
|
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 SZ 7 RT 42-5020-062-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3491508
|
|
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 PS STD SZ 4 RT NITRIDED 42-5706-056-02
|
Facility
|
IP
|
$12,962.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5823635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,351.38 |
| Max. Negotiated Rate |
$11,925.04 |
| Rate for Payer: Aetna Commercial |
$11,665.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,147.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,869.86
|
| Rate for Payer: Cash Price |
$3,888.60
|
| Rate for Payer: Cigna Commercial |
$11,925.04
|
| Rate for Payer: Health EOS Commercial |
$11,536.18
|
| Rate for Payer: HFN Commercial |
$11,925.04
|
| Rate for Payer: Multiplan Commercial |
$10,369.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,777.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,925.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,351.38
|
| Rate for Payer: Quartz Commercial |
$7,777.20
|
| Rate for Payer: WEA Trust Commercial |
$7,129.10
|
| Rate for Payer: WPS Commercial |
$9,600.95
|
|
|
FEMUR PERSONA PS STD SZ 4 RT NITRIDED 42-5706-056-02
|
Facility
|
OP
|
$12,962.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5823635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,629.36 |
| Max. Negotiated Rate |
$51,848.00 |
| Rate for Payer: Aetna Commercial |
$11,665.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,147.32
|
| Rate for Payer: Aetna Managed Medicare |
$3,629.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,425.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,481.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,221.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,869.86
|
| Rate for Payer: Cash Price |
$3,888.60
|
| Rate for Payer: Cigna Commercial |
$11,925.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,253.54
|
| Rate for Payer: Health EOS Commercial |
$11,536.18
|
| Rate for Payer: HFN Commercial |
$11,925.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,721.50
|
| Rate for Payer: Multiplan Commercial |
$10,369.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,777.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,925.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,351.38
|
| Rate for Payer: Quartz Commercial |
$8,425.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,777.20
|
| Rate for Payer: The Alliance Commercial |
$51,848.00
|
| Rate for Payer: WEA Trust Commercial |
$7,129.10
|
| Rate for Payer: WPS Commercial |
$9,600.95
|
|
|
FEMUR PERSONA PS STD SZ 5 LT NITRIDED 42-5706-058-01
|
Facility
|
IP
|
$12,584.00
|
|
| Hospital Charge Code |
6217103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,166.16 |
| Max. Negotiated Rate |
$11,577.28 |
| Rate for Payer: Aetna Commercial |
$11,325.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,822.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,669.52
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cigna Commercial |
$11,577.28
|
| Rate for Payer: Health EOS Commercial |
$11,199.76
|
| Rate for Payer: HFN Commercial |
$11,577.28
|
| Rate for Payer: Multiplan Commercial |
$10,067.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,550.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,577.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,166.16
|
| Rate for Payer: Quartz Commercial |
$7,550.40
|
| Rate for Payer: WEA Trust Commercial |
$6,921.20
|
| Rate for Payer: WPS Commercial |
$9,320.97
|
|
|
FEMUR PERSONA PS STD SZ 5 LT NITRIDED 42-5706-058-01
|
Facility
|
OP
|
$12,584.00
|
|
| Hospital Charge Code |
6217103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,523.52 |
| Max. Negotiated Rate |
$50,336.00 |
| Rate for Payer: Aetna Commercial |
$11,325.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,822.24
|
| Rate for Payer: Aetna Managed Medicare |
$3,523.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,179.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,292.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,040.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,669.52
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cigna Commercial |
$11,577.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,042.01
|
| Rate for Payer: Health EOS Commercial |
$11,199.76
|
| Rate for Payer: HFN Commercial |
$11,577.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,438.00
|
| Rate for Payer: Multiplan Commercial |
$10,067.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,550.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,577.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,166.16
|
| Rate for Payer: Quartz Commercial |
$8,179.60
|
| Rate for Payer: Quartz Medicare Advantage |
$7,550.40
|
| Rate for Payer: The Alliance Commercial |
$50,336.00
|
| Rate for Payer: WEA Trust Commercial |
$6,921.20
|
| Rate for Payer: WPS Commercial |
$9,320.97
|
|
|
FEMUR PERSONA PS STD SZ 5 RT NITRIDED 42-5706-058-02
|
Facility
|
OP
|
$11,984.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6198978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,355.52 |
| Max. Negotiated Rate |
$47,936.00 |
| Rate for Payer: Aetna Commercial |
$10,785.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,306.24
|
| Rate for Payer: Aetna Managed Medicare |
$3,355.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,789.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,992.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,752.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,351.52
|
| Rate for Payer: Cash Price |
$3,595.20
|
| Rate for Payer: Cigna Commercial |
$11,025.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,706.25
|
| Rate for Payer: Health EOS Commercial |
$10,665.76
|
| Rate for Payer: HFN Commercial |
$11,025.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,988.00
|
| Rate for Payer: Multiplan Commercial |
$9,587.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,190.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,025.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,872.16
|
| Rate for Payer: Quartz Commercial |
$7,789.60
|
| Rate for Payer: Quartz Medicare Advantage |
$7,190.40
|
| Rate for Payer: The Alliance Commercial |
$47,936.00
|
| Rate for Payer: WEA Trust Commercial |
$6,591.20
|
| Rate for Payer: WPS Commercial |
$8,876.55
|
|
|
FEMUR PERSONA PS STD SZ 5 RT NITRIDED 42-5706-058-02
|
Facility
|
IP
|
$11,984.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6198978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,872.16 |
| Max. Negotiated Rate |
$11,025.28 |
| Rate for Payer: Aetna Commercial |
$10,785.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,306.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,351.52
|
| Rate for Payer: Cash Price |
$3,595.20
|
| Rate for Payer: Cigna Commercial |
$11,025.28
|
| Rate for Payer: Health EOS Commercial |
$10,665.76
|
| Rate for Payer: HFN Commercial |
$11,025.28
|
| Rate for Payer: Multiplan Commercial |
$9,587.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,190.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,025.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,872.16
|
| Rate for Payer: Quartz Commercial |
$7,190.40
|
| Rate for Payer: WEA Trust Commercial |
$6,591.20
|
| Rate for Payer: WPS Commercial |
$8,876.55
|
|
|
FEMUR PERSONA PS STD SZ 8 LEFT NITRIDED 42-5706-064-01
|
Facility
|
IP
|
$13,480.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,605.20 |
| Max. Negotiated Rate |
$12,401.60 |
| Rate for Payer: Aetna Commercial |
$12,132.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,592.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,144.40
|
| Rate for Payer: Cash Price |
$4,044.00
|
| Rate for Payer: Cigna Commercial |
$12,401.60
|
| Rate for Payer: Health EOS Commercial |
$11,997.20
|
| Rate for Payer: HFN Commercial |
$12,401.60
|
| Rate for Payer: Multiplan Commercial |
$10,784.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,088.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,401.60
|
| Rate for Payer: Quartz Beloit One Network |
$6,605.20
|
| Rate for Payer: Quartz Commercial |
$8,088.00
|
| Rate for Payer: WEA Trust Commercial |
$7,414.00
|
| Rate for Payer: WPS Commercial |
$9,984.64
|
|
|
FEMUR PERSONA PS STD SZ 8 LEFT NITRIDED 42-5706-064-01
|
Facility
|
OP
|
$13,480.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,774.40 |
| Max. Negotiated Rate |
$53,920.00 |
| Rate for Payer: Aetna Commercial |
$12,132.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,592.80
|
| Rate for Payer: Aetna Managed Medicare |
$3,774.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,762.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,740.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,470.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,144.40
|
| Rate for Payer: Cash Price |
$4,044.00
|
| Rate for Payer: Cigna Commercial |
$12,401.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,543.41
|
| Rate for Payer: Health EOS Commercial |
$11,997.20
|
| Rate for Payer: HFN Commercial |
$12,401.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,110.00
|
| Rate for Payer: Multiplan Commercial |
$10,784.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,088.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,401.60
|
| Rate for Payer: Quartz Beloit One Network |
$6,605.20
|
| Rate for Payer: Quartz Commercial |
$8,762.00
|
| Rate for Payer: Quartz Medicare Advantage |
$8,088.00
|
| Rate for Payer: The Alliance Commercial |
$53,920.00
|
| Rate for Payer: WEA Trust Commercial |
$7,414.00
|
| Rate for Payer: WPS Commercial |
$9,984.64
|
|
