|
FEMUR TRIATHLON PS SZ 3 RT 5515-F-302
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493865
|
|
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 PS SZ 3 RT 5515-F-302
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493865
|
|
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 PS SZ 4 LT 5515-F-401
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493866
|
|
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 PS SZ 4 LT 5515-F-401
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493866
|
|
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 PS SZ 4 RT 5515-F-402
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4291233
|
|
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 PS SZ 4 RT 5515-F-402
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4291233
|
|
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 PS SZ 5 LT 5515-F-501
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3881347
|
|
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 PS SZ 5 LT 5515-F-501
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3881347
|
|
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 PS SZ 5 RT 5515-F-502
|
Facility
|
OP
|
$12,032.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493867
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,503.72 |
| Max. Negotiated Rate |
$11,512.22 |
| Rate for Payer: Aetna Commercial |
$11,261.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,761.42
|
| Rate for Payer: Aetna Managed Medicare |
$3,503.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,133.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,256.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,006.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,632.04
|
| Rate for Payer: Cash Price |
$3,609.60
|
| Rate for Payer: Cigna Commercial |
$11,512.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,002.62
|
| Rate for Payer: Health EOS Commercial |
$11,136.82
|
| Rate for Payer: HFN Commercial |
$11,512.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,384.96
|
| Rate for Payer: Multiplan Commercial |
$10,010.62
|
| Rate for Payer: NAPHCARE Commercial |
$7,507.97
|
| Rate for Payer: Preferred Network Access Commercial |
$11,512.22
|
| Rate for Payer: Quartz Beloit One Network |
$6,131.51
|
| Rate for Payer: Quartz Commercial |
$8,133.63
|
| Rate for Payer: Quartz Medicare Advantage |
$7,507.97
|
| Rate for Payer: The Alliance Commercial |
$6,256.64
|
| Rate for Payer: WEA Trust Commercial |
$6,882.30
|
| Rate for Payer: WPS Commercial |
$9,268.25
|
|
|
FEMUR TRIATHLON PS SZ 5 RT 5515-F-502
|
Facility
|
IP
|
$12,032.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493867
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,131.51 |
| Max. Negotiated Rate |
$11,512.22 |
| Rate for Payer: Aetna Commercial |
$11,261.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,761.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,632.04
|
| Rate for Payer: Cash Price |
$3,609.60
|
| Rate for Payer: Cigna Commercial |
$11,512.22
|
| Rate for Payer: Health EOS Commercial |
$11,136.82
|
| Rate for Payer: HFN Commercial |
$11,512.22
|
| Rate for Payer: Multiplan Commercial |
$10,010.62
|
| Rate for Payer: Preferred Network Access Commercial |
$11,512.22
|
| Rate for Payer: Quartz Beloit One Network |
$6,131.51
|
| Rate for Payer: Quartz Commercial |
$7,507.97
|
| Rate for Payer: WEA Trust Commercial |
$6,882.30
|
| Rate for Payer: WPS Commercial |
$9,268.25
|
|
|
FEMUR TRIATHLON PS SZ 6 LT 5515-F-601
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493868
|
|
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 PS SZ 6 LT 5515-F-601
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493868
|
|
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 PS SZ 7 LT 5515-F-701
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493870
|
|
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 PS SZ 7 LT 5515-F-701
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493870
|
|
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 PS SZ 7 RT 5515-F-702
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493872
|
|
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 PS SZ 7 RT 5515-F-702
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493872
|
|
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 PS SZ 8 LT 5515-F-801
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493875
|
|
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 PS SZ 8 LT 5515-F-801
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493875
|
|
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 PS SZ 8 RT 5515-F-802
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493877
|
|
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 PS SZ 8 RT 5515-F-802
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493877
|
|
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 ZUK HIGH FLEX SZ B RT MED/LT LAT 5842-12-02
|
Facility
|
IP
|
$8,140.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,148.14 |
| Max. Negotiated Rate |
$7,788.35 |
| Rate for Payer: Aetna Commercial |
$7,619.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,280.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,486.77
|
| Rate for Payer: Cash Price |
$2,442.00
|
| Rate for Payer: Cigna Commercial |
$7,788.35
|
| Rate for Payer: Health EOS Commercial |
$7,534.38
|
| Rate for Payer: HFN Commercial |
$7,788.35
|
| Rate for Payer: Multiplan Commercial |
$6,772.48
|
| Rate for Payer: Preferred Network Access Commercial |
$7,788.35
|
| Rate for Payer: Quartz Beloit One Network |
$4,148.14
|
| Rate for Payer: Quartz Commercial |
$5,079.36
|
| Rate for Payer: WEA Trust Commercial |
$4,656.08
|
| Rate for Payer: WPS Commercial |
$6,270.24
|
|
|
FEMUR ZUK HIGH FLEX SZ B RT MED/LT LAT 5842-12-02
|
Facility
|
OP
|
$8,140.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,370.37 |
| Max. Negotiated Rate |
$7,788.35 |
| Rate for Payer: Aetna Commercial |
$7,619.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,280.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,370.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,502.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,232.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,063.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,486.77
|
| Rate for Payer: Cash Price |
$2,442.00
|
| Rate for Payer: Cigna Commercial |
$7,788.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,737.48
|
| Rate for Payer: Health EOS Commercial |
$7,534.38
|
| Rate for Payer: HFN Commercial |
$7,788.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,349.20
|
| Rate for Payer: Multiplan Commercial |
$6,772.48
|
| Rate for Payer: NAPHCARE Commercial |
$5,079.36
|
| Rate for Payer: Preferred Network Access Commercial |
$7,788.35
|
| Rate for Payer: Quartz Beloit One Network |
$4,148.14
|
| Rate for Payer: Quartz Commercial |
$5,502.64
|
| Rate for Payer: Quartz Medicare Advantage |
$5,079.36
|
| Rate for Payer: The Alliance Commercial |
$4,232.80
|
| Rate for Payer: WEA Trust Commercial |
$4,656.08
|
| Rate for Payer: WPS Commercial |
$6,270.24
|
|
|
fentanyl 100mcg/2ml syringe [Med]
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
2983104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.36
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$4.95
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$2.58
|
|
|
fentanyl 100mcg/2ml syringe [Med]
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
2983104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
Fentanyl 50mcg/2ml syringe [Med]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
5286879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$4.99
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
