|
FEMUR PSN PS CMT CCR STD RT SZ 9 42-5006-066-02
|
Facility
|
OP
|
$20,886.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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, TENDON & NERVE REPAIR
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2960418
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FEMUR, TENDON & NERVE REPAIR
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2960418
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FEMUR TRIATHLON CR SZ 2 LT 5510-F-201
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.14 |
| Max. Negotiated Rate |
$10,659.12 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$6,951.60
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON CR SZ 2 LT 5510-F-201
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,244.08 |
| Max. Negotiated Rate |
$46,344.00 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,244.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,530.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,483.53
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,689.50
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$7,530.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,951.60
|
| Rate for Payer: The Alliance Commercial |
$46,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON CR SZ 2 LT 5517-F-201
|
Facility
|
OP
|
$19,515.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4343565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,464.20 |
| Max. Negotiated Rate |
$78,060.00 |
| Rate for Payer: Aetna Commercial |
$17,563.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,782.90
|
| Rate for Payer: Aetna Managed Medicare |
$5,464.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,684.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,757.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,367.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,342.95
|
| Rate for Payer: Cash Price |
$5,854.50
|
| Rate for Payer: Cigna Commercial |
$17,953.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,920.59
|
| Rate for Payer: Health EOS Commercial |
$17,368.35
|
| Rate for Payer: HFN Commercial |
$17,953.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,636.25
|
| Rate for Payer: Multiplan Commercial |
$15,612.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,709.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,953.80
|
| Rate for Payer: Quartz Beloit One Network |
$9,562.35
|
| Rate for Payer: Quartz Commercial |
$12,684.75
|
| Rate for Payer: Quartz Medicare Advantage |
$11,709.00
|
| Rate for Payer: The Alliance Commercial |
$78,060.00
|
| Rate for Payer: WEA Trust Commercial |
$10,733.25
|
| Rate for Payer: WPS Commercial |
$14,454.76
|
|
|
FEMUR TRIATHLON CR SZ 2 LT 5517-F-201
|
Facility
|
IP
|
$19,515.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4343565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,562.35 |
| Max. Negotiated Rate |
$17,953.80 |
| Rate for Payer: Aetna Commercial |
$17,563.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,782.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,342.95
|
| Rate for Payer: Cash Price |
$5,854.50
|
| Rate for Payer: Cigna Commercial |
$17,953.80
|
| Rate for Payer: Health EOS Commercial |
$17,368.35
|
| Rate for Payer: HFN Commercial |
$17,953.80
|
| Rate for Payer: Multiplan Commercial |
$15,612.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,709.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,953.80
|
| Rate for Payer: Quartz Beloit One Network |
$9,562.35
|
| Rate for Payer: Quartz Commercial |
$11,709.00
|
| Rate for Payer: WEA Trust Commercial |
$10,733.25
|
| Rate for Payer: WPS Commercial |
$14,454.76
|
|
|
FEMUR TRIATHLON CR SZ 2 RT 5517-F-202
|
Facility
|
IP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,929.36 |
| Max. Negotiated Rate |
$18,642.88 |
| Rate for Payer: Aetna Commercial |
$18,237.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,427.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,739.92
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$18,642.88
|
| Rate for Payer: Health EOS Commercial |
$18,034.96
|
| Rate for Payer: HFN Commercial |
$18,642.88
|
| Rate for Payer: Multiplan Commercial |
$16,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,642.88
|
| Rate for Payer: Quartz Beloit One Network |
$9,929.36
|
| Rate for Payer: Quartz Commercial |
$12,158.40
|
| Rate for Payer: WEA Trust Commercial |
$11,145.20
|
| Rate for Payer: WPS Commercial |
$15,009.54
|
|
|
FEMUR TRIATHLON CR SZ 2 RT 5517-F-202
|
Facility
|
OP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,673.92 |
| Max. Negotiated Rate |
$81,056.00 |
| Rate for Payer: Aetna Commercial |
$18,237.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,427.04
|
| Rate for Payer: Aetna Managed Medicare |
$5,673.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,171.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,132.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,726.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,739.92
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$18,642.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,339.73
|
| Rate for Payer: Health EOS Commercial |
$18,034.96
|
| Rate for Payer: HFN Commercial |
$18,642.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,198.00
|
| Rate for Payer: Multiplan Commercial |
$16,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,642.88
|
| Rate for Payer: Quartz Beloit One Network |
$9,929.36
|
| Rate for Payer: Quartz Commercial |
$13,171.60
|
| Rate for Payer: Quartz Medicare Advantage |
$12,158.40
|
| Rate for Payer: The Alliance Commercial |
$81,056.00
|
| Rate for Payer: WEA Trust Commercial |
$11,145.20
|
| Rate for Payer: WPS Commercial |
$15,009.54
|
|
|
FEMUR TRIATHLON CR SZ 3 LT 5510-F-301
|
Facility
|
OP
|
$11,591.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3072401
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,245.48 |
| Max. Negotiated Rate |
$46,364.00 |
| Rate for Payer: Aetna Commercial |
$10,431.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,968.26
|
| Rate for Payer: Aetna Managed Medicare |
$3,245.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,534.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,795.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,563.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,143.23
|
| Rate for Payer: Cash Price |
$3,477.30
|
| Rate for Payer: Cigna Commercial |
$10,663.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,486.32
|
| Rate for Payer: Health EOS Commercial |
$10,315.99
|
| Rate for Payer: HFN Commercial |
$10,663.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,693.25
|
| Rate for Payer: Multiplan Commercial |
$9,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,954.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,663.72
|
| Rate for Payer: Quartz Beloit One Network |
$5,679.59
|
| Rate for Payer: Quartz Commercial |
$7,534.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,954.60
|
| Rate for Payer: The Alliance Commercial |
$46,364.00
|
| Rate for Payer: WEA Trust Commercial |
$6,375.05
|
| Rate for Payer: WPS Commercial |
$8,585.45
|
|
|
FEMUR TRIATHLON CR SZ 3 LT 5510-F-301
|
Facility
|
IP
|
$11,591.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3072401
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,679.59 |
| Max. Negotiated Rate |
$10,663.72 |
| Rate for Payer: Aetna Commercial |
$10,431.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,968.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,143.23
|
| Rate for Payer: Cash Price |
$3,477.30
|
| Rate for Payer: Cigna Commercial |
$10,663.72
|
| Rate for Payer: Health EOS Commercial |
$10,315.99
|
| Rate for Payer: HFN Commercial |
$10,663.72
|
| Rate for Payer: Multiplan Commercial |
$9,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,954.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,663.72
|
| Rate for Payer: Quartz Beloit One Network |
$5,679.59
|
| Rate for Payer: Quartz Commercial |
$6,954.60
|
| Rate for Payer: WEA Trust Commercial |
$6,375.05
|
| Rate for Payer: WPS Commercial |
$8,585.45
|
|
|
FEMUR TRIATHLON CR SZ 3 LT 5517-F-301
|
Facility
|
OP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779539
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,673.92 |
| Max. Negotiated Rate |
$81,056.00 |
| Rate for Payer: Aetna Commercial |
$18,237.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,427.04
|
| Rate for Payer: Aetna Managed Medicare |
$5,673.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,171.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,132.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,726.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,739.92
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$18,642.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,339.73
|
| Rate for Payer: Health EOS Commercial |
$18,034.96
|
| Rate for Payer: HFN Commercial |
$18,642.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,198.00
|
| Rate for Payer: Multiplan Commercial |
$16,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,642.88
|
| Rate for Payer: Quartz Beloit One Network |
$9,929.36
|
| Rate for Payer: Quartz Commercial |
$13,171.60
|
| Rate for Payer: Quartz Medicare Advantage |
$12,158.40
|
| Rate for Payer: The Alliance Commercial |
$81,056.00
|
| Rate for Payer: WEA Trust Commercial |
$11,145.20
|
| Rate for Payer: WPS Commercial |
$15,009.54
|
|
|
FEMUR TRIATHLON CR SZ 3 LT 5517-F-301
|
Facility
|
IP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779539
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,929.36 |
| Max. Negotiated Rate |
$18,642.88 |
| Rate for Payer: Aetna Commercial |
$18,237.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,427.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,739.92
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$18,642.88
|
| Rate for Payer: Health EOS Commercial |
$18,034.96
|
| Rate for Payer: HFN Commercial |
$18,642.88
|
| Rate for Payer: Multiplan Commercial |
$16,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,642.88
|
| Rate for Payer: Quartz Beloit One Network |
$9,929.36
|
| Rate for Payer: Quartz Commercial |
$12,158.40
|
| Rate for Payer: WEA Trust Commercial |
$11,145.20
|
| Rate for Payer: WPS Commercial |
$15,009.54
|
|
|
FEMUR TRIATHLON CR SZ 3 RT 5510-F-302
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177478
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.14 |
| Max. Negotiated Rate |
$10,659.12 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$6,951.60
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON CR SZ 3 RT 5510-F-302
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177478
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,244.08 |
| Max. Negotiated Rate |
$46,344.00 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,244.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,530.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,483.53
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,689.50
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$7,530.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,951.60
|
| Rate for Payer: The Alliance Commercial |
$46,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON CR SZ 3 RT 5517-F-302
|
Facility
|
IP
|
$19,515.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,562.35 |
| Max. Negotiated Rate |
$17,953.80 |
| Rate for Payer: Aetna Commercial |
$17,563.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,782.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,342.95
|
| Rate for Payer: Cash Price |
$5,854.50
|
| Rate for Payer: Cigna Commercial |
$17,953.80
|
| Rate for Payer: Health EOS Commercial |
$17,368.35
|
| Rate for Payer: HFN Commercial |
$17,953.80
|
| Rate for Payer: Multiplan Commercial |
$15,612.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,709.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,953.80
|
| Rate for Payer: Quartz Beloit One Network |
$9,562.35
|
| Rate for Payer: Quartz Commercial |
$11,709.00
|
| Rate for Payer: WEA Trust Commercial |
$10,733.25
|
| Rate for Payer: WPS Commercial |
$14,454.76
|
|
|
FEMUR TRIATHLON CR SZ 3 RT 5517-F-302
|
Facility
|
OP
|
$19,515.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,464.20 |
| Max. Negotiated Rate |
$78,060.00 |
| Rate for Payer: Aetna Commercial |
$17,563.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,782.90
|
| Rate for Payer: Aetna Managed Medicare |
$5,464.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,684.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,757.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,367.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,342.95
|
| Rate for Payer: Cash Price |
$5,854.50
|
| Rate for Payer: Cigna Commercial |
$17,953.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,920.59
|
| Rate for Payer: Health EOS Commercial |
$17,368.35
|
| Rate for Payer: HFN Commercial |
$17,953.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,636.25
|
| Rate for Payer: Multiplan Commercial |
$15,612.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,709.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,953.80
|
| Rate for Payer: Quartz Beloit One Network |
$9,562.35
|
| Rate for Payer: Quartz Commercial |
$12,684.75
|
| Rate for Payer: Quartz Medicare Advantage |
$11,709.00
|
| Rate for Payer: The Alliance Commercial |
$78,060.00
|
| Rate for Payer: WEA Trust Commercial |
$10,733.25
|
| Rate for Payer: WPS Commercial |
$14,454.76
|
|
|
FEMUR TRIATHLON CR SZ 4 LT 5510-F-401
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3128845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,244.08 |
| Max. Negotiated Rate |
$46,344.00 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,244.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,530.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,483.53
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,689.50
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$7,530.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,951.60
|
| Rate for Payer: The Alliance Commercial |
$46,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON CR SZ 4 LT 5510-F-401
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3128845
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.14 |
| Max. Negotiated Rate |
$10,659.12 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$6,951.60
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON CR SZ 4 LT 5517-F-401
|
Facility
|
OP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,673.92 |
| Max. Negotiated Rate |
$81,056.00 |
| Rate for Payer: Aetna Commercial |
$18,237.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,427.04
|
| Rate for Payer: Aetna Managed Medicare |
$5,673.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,171.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,132.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,726.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,739.92
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$18,642.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,339.73
|
| Rate for Payer: Health EOS Commercial |
$18,034.96
|
| Rate for Payer: HFN Commercial |
$18,642.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,198.00
|
| Rate for Payer: Multiplan Commercial |
$16,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,642.88
|
| Rate for Payer: Quartz Beloit One Network |
$9,929.36
|
| Rate for Payer: Quartz Commercial |
$13,171.60
|
| Rate for Payer: Quartz Medicare Advantage |
$12,158.40
|
| Rate for Payer: The Alliance Commercial |
$81,056.00
|
| Rate for Payer: WEA Trust Commercial |
$11,145.20
|
| Rate for Payer: WPS Commercial |
$15,009.54
|
|
|
FEMUR TRIATHLON CR SZ 4 LT 5517-F-401
|
Facility
|
IP
|
$20,264.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,929.36 |
| Max. Negotiated Rate |
$18,642.88 |
| Rate for Payer: Aetna Commercial |
$18,237.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,427.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,739.92
|
| Rate for Payer: Cash Price |
$6,079.20
|
| Rate for Payer: Cigna Commercial |
$18,642.88
|
| Rate for Payer: Health EOS Commercial |
$18,034.96
|
| Rate for Payer: HFN Commercial |
$18,642.88
|
| Rate for Payer: Multiplan Commercial |
$16,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,642.88
|
| Rate for Payer: Quartz Beloit One Network |
$9,929.36
|
| Rate for Payer: Quartz Commercial |
$12,158.40
|
| Rate for Payer: WEA Trust Commercial |
$11,145.20
|
| Rate for Payer: WPS Commercial |
$15,009.54
|
|
|
FEMUR TRIATHLON CR SZ 4 RT 5510-F-402
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3263467
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,244.08 |
| Max. Negotiated Rate |
$46,344.00 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Aetna Managed Medicare |
$3,244.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,530.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,561.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,483.53
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,689.50
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$7,530.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,951.60
|
| Rate for Payer: The Alliance Commercial |
$46,344.00
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON CR SZ 4 RT 5510-F-402
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3263467
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.14 |
| Max. Negotiated Rate |
$10,659.12 |
| Rate for Payer: Aetna Commercial |
$10,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,963.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,140.58
|
| Rate for Payer: Cash Price |
$3,475.80
|
| Rate for Payer: Cigna Commercial |
$10,659.12
|
| Rate for Payer: Health EOS Commercial |
$10,311.54
|
| Rate for Payer: HFN Commercial |
$10,659.12
|
| Rate for Payer: Multiplan Commercial |
$9,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,659.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,677.14
|
| Rate for Payer: Quartz Commercial |
$6,951.60
|
| Rate for Payer: WEA Trust Commercial |
$6,372.30
|
| Rate for Payer: WPS Commercial |
$8,581.75
|
|
|
FEMUR TRIATHLON CR SZ 4 RT 5517-F-402
|
Facility
|
OP
|
$19,515.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4263464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,464.20 |
| Max. Negotiated Rate |
$78,060.00 |
| Rate for Payer: Aetna Commercial |
$17,563.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,782.90
|
| Rate for Payer: Aetna Managed Medicare |
$5,464.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,684.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,757.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,367.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,342.95
|
| Rate for Payer: Cash Price |
$5,854.50
|
| Rate for Payer: Cigna Commercial |
$17,953.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,920.59
|
| Rate for Payer: Health EOS Commercial |
$17,368.35
|
| Rate for Payer: HFN Commercial |
$17,953.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,636.25
|
| Rate for Payer: Multiplan Commercial |
$15,612.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,709.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,953.80
|
| Rate for Payer: Quartz Beloit One Network |
$9,562.35
|
| Rate for Payer: Quartz Commercial |
$12,684.75
|
| Rate for Payer: Quartz Medicare Advantage |
$11,709.00
|
| Rate for Payer: The Alliance Commercial |
$78,060.00
|
| Rate for Payer: WEA Trust Commercial |
$10,733.25
|
| Rate for Payer: WPS Commercial |
$14,454.76
|
|
|
FEMUR TRIATHLON CR SZ 4 RT 5517-F-402
|
Facility
|
IP
|
$19,515.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4263464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,562.35 |
| Max. Negotiated Rate |
$17,953.80 |
| Rate for Payer: Aetna Commercial |
$17,563.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,782.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,342.95
|
| Rate for Payer: Cash Price |
$5,854.50
|
| Rate for Payer: Cigna Commercial |
$17,953.80
|
| Rate for Payer: Health EOS Commercial |
$17,368.35
|
| Rate for Payer: HFN Commercial |
$17,953.80
|
| Rate for Payer: Multiplan Commercial |
$15,612.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,709.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,953.80
|
| Rate for Payer: Quartz Beloit One Network |
$9,562.35
|
| Rate for Payer: Quartz Commercial |
$11,709.00
|
| Rate for Payer: WEA Trust Commercial |
$10,733.25
|
| Rate for Payer: WPS Commercial |
$14,454.76
|
|
