|
FEMUR PSN PS CMT CCR STD LT SZ 5 42-5006-058-01
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD LT SZ 5 42-5006-058-01
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| 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 PSN PS CMT CCR STD LT SZ 6 42-5006-060-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 PSN PS CMT CCR STD LT SZ 6 42-5006-060-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD LT SZ 7 42-5006-062-01
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3337518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| 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 PSN PS CMT CCR STD LT SZ 7 42-5006-062-01
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3337518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD LT SZ 8 42-5006-064-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3241466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 PSN PS CMT CCR STD LT SZ 8 42-5006-064-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3241466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD LT SZ 9 42-5006-066-01
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD LT SZ 9 42-5006-066-01
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 PSN PS CMT CCR STD RT SZ 10 42-5006-068-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3827382
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD RT SZ 10 42-5006-068-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3827382
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 PSN PS CMT CCR STD RT SZ 11 42-5006-070-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3110204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD RT SZ 11 42-5006-070-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3110204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 PSN PS CMT CCR STD RT SZ 12 42-5006-074-02
|
Facility
|
IP
|
$8,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,201.26 |
| Max. Negotiated Rate |
$7,888.08 |
| Rate for Payer: Aetna Commercial |
$7,716.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,373.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,544.22
|
| Rate for Payer: Cash Price |
$2,572.20
|
| Rate for Payer: Cigna Commercial |
$7,888.08
|
| Rate for Payer: Health EOS Commercial |
$7,630.86
|
| Rate for Payer: HFN Commercial |
$7,888.08
|
| Rate for Payer: Multiplan Commercial |
$6,859.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,144.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,888.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,201.26
|
| Rate for Payer: Quartz Commercial |
$5,144.40
|
| Rate for Payer: WEA Trust Commercial |
$4,715.70
|
| Rate for Payer: WPS Commercial |
$6,350.76
|
|
|
FEMUR PSN PS CMT CCR STD RT SZ 12 42-5006-074-02
|
Facility
|
OP
|
$8,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,400.72 |
| Max. Negotiated Rate |
$34,296.00 |
| Rate for Payer: Aetna Commercial |
$7,716.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,373.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,400.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,573.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,115.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,544.22
|
| Rate for Payer: Cash Price |
$2,572.20
|
| Rate for Payer: Cigna Commercial |
$7,888.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,798.01
|
| Rate for Payer: Health EOS Commercial |
$7,630.86
|
| Rate for Payer: HFN Commercial |
$7,888.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,430.50
|
| Rate for Payer: Multiplan Commercial |
$6,859.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,144.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,888.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,201.26
|
| Rate for Payer: Quartz Commercial |
$5,573.10
|
| Rate for Payer: Quartz Medicare Advantage |
$5,144.40
|
| Rate for Payer: The Alliance Commercial |
$34,296.00
|
| Rate for Payer: WEA Trust Commercial |
$4,715.70
|
| Rate for Payer: WPS Commercial |
$6,350.76
|
|
|
FEMUR PSN PS CMT CCR STD RT SZ 5 42-5006-058-02
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| 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 PSN PS CMT CCR STD RT SZ 5 42-5006-058-02
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD RT SZ 6 42-5006-060-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD RT SZ 6 42-5006-060-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3950689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 PSN PS CMT CCR STD RT SZ 7 42-5006-062-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3285464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 PSN PS CMT CCR STD RT SZ 7 42-5006-062-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3285464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD RT SZ 8 42-5006-064-02
|
Facility
|
OP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615495
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,072.92 |
| 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 PSN PS CMT CCR STD RT SZ 8 42-5006-064-02
|
Facility
|
IP
|
$21,689.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615495
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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 PSN PS CMT CCR STD RT SZ 9 42-5006-066-02
|
Facility
|
IP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,234.14 |
| 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
|
|
