|
FEMUR TRIATHLON CR SZ 8 LT 5510-F-801
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493860
|
|
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 8 LT 5517-F-801
|
Facility
|
IP
|
$23,173.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493883
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,354.77 |
| Max. Negotiated Rate |
$21,319.16 |
| Rate for Payer: Aetna Commercial |
$20,855.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,928.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,281.69
|
| Rate for Payer: Cash Price |
$6,951.90
|
| Rate for Payer: Cigna Commercial |
$21,319.16
|
| Rate for Payer: Health EOS Commercial |
$20,623.97
|
| Rate for Payer: HFN Commercial |
$21,319.16
|
| Rate for Payer: Multiplan Commercial |
$18,538.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,903.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21,319.16
|
| Rate for Payer: Quartz Beloit One Network |
$11,354.77
|
| Rate for Payer: Quartz Commercial |
$13,903.80
|
| Rate for Payer: WEA Trust Commercial |
$12,745.15
|
| Rate for Payer: WPS Commercial |
$17,164.24
|
|
|
FEMUR TRIATHLON CR SZ 8 LT 5517-F-801
|
Facility
|
OP
|
$23,173.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493883
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,488.44 |
| Max. Negotiated Rate |
$92,692.00 |
| Rate for Payer: Aetna Commercial |
$20,855.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,928.78
|
| Rate for Payer: Aetna Managed Medicare |
$6,488.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,062.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,586.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,123.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,281.69
|
| Rate for Payer: Cash Price |
$6,951.90
|
| Rate for Payer: Cigna Commercial |
$21,319.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,967.61
|
| Rate for Payer: Health EOS Commercial |
$20,623.97
|
| Rate for Payer: HFN Commercial |
$21,319.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,379.75
|
| Rate for Payer: Multiplan Commercial |
$18,538.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,903.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21,319.16
|
| Rate for Payer: Quartz Beloit One Network |
$11,354.77
|
| Rate for Payer: Quartz Commercial |
$15,062.45
|
| Rate for Payer: Quartz Medicare Advantage |
$13,903.80
|
| Rate for Payer: The Alliance Commercial |
$92,692.00
|
| Rate for Payer: WEA Trust Commercial |
$12,745.15
|
| Rate for Payer: WPS Commercial |
$17,164.24
|
|
|
FEMUR TRIATHLON CR SZ 8 RT 5510-F-802
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493861
|
|
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 8 RT 5510-F-802
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493861
|
|
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 8 RT 5517-F-802
|
Facility
|
IP
|
$23,173.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493742
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,354.77 |
| Max. Negotiated Rate |
$21,319.16 |
| Rate for Payer: Aetna Commercial |
$20,855.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,928.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,281.69
|
| Rate for Payer: Cash Price |
$6,951.90
|
| Rate for Payer: Cigna Commercial |
$21,319.16
|
| Rate for Payer: Health EOS Commercial |
$20,623.97
|
| Rate for Payer: HFN Commercial |
$21,319.16
|
| Rate for Payer: Multiplan Commercial |
$18,538.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,903.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21,319.16
|
| Rate for Payer: Quartz Beloit One Network |
$11,354.77
|
| Rate for Payer: Quartz Commercial |
$13,903.80
|
| Rate for Payer: WEA Trust Commercial |
$12,745.15
|
| Rate for Payer: WPS Commercial |
$17,164.24
|
|
|
FEMUR TRIATHLON CR SZ 8 RT 5517-F-802
|
Facility
|
OP
|
$23,173.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493742
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,488.44 |
| Max. Negotiated Rate |
$92,692.00 |
| Rate for Payer: Aetna Commercial |
$20,855.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,928.78
|
| Rate for Payer: Aetna Managed Medicare |
$6,488.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,062.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,586.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,123.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,281.69
|
| Rate for Payer: Cash Price |
$6,951.90
|
| Rate for Payer: Cigna Commercial |
$21,319.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,967.61
|
| Rate for Payer: Health EOS Commercial |
$20,623.97
|
| Rate for Payer: HFN Commercial |
$21,319.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,379.75
|
| Rate for Payer: Multiplan Commercial |
$18,538.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,903.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21,319.16
|
| Rate for Payer: Quartz Beloit One Network |
$11,354.77
|
| Rate for Payer: Quartz Commercial |
$15,062.45
|
| Rate for Payer: Quartz Medicare Advantage |
$13,903.80
|
| Rate for Payer: The Alliance Commercial |
$92,692.00
|
| Rate for Payer: WEA Trust Commercial |
$12,745.15
|
| Rate for Payer: WPS Commercial |
$17,164.24
|
|
|
FEMUR TRIATHLON PS SZ 2 LT 5515-F-201
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493862
|
|
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 PS SZ 2 LT 5515-F-201
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493862
|
|
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 PS SZ 2 RT 5515-F-202
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493863
|
|
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 PS SZ 2 RT 5515-F-202
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493863
|
|
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 PS SZ 3 LT 5515-F-301
|
Facility
|
OP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3505527
|
|
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 PS SZ 3 LT 5515-F-301
|
Facility
|
IP
|
$11,586.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3505527
|
|
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 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 |
$5,677.14 |
| 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 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 |
$3,244.08 |
| 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 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 |
$3,244.08 |
| 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 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 |
$5,677.14 |
| 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 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 |
$3,244.08 |
| 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 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 |
$5,677.14 |
| 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 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 |
$3,244.08 |
| 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 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 |
$5,677.14 |
| 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 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 |
$3,368.96 |
| Max. Negotiated Rate |
$48,128.00 |
| Rate for Payer: Aetna Commercial |
$10,828.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,347.52
|
| Rate for Payer: Aetna Managed Medicare |
$3,368.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,820.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,016.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,775.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,376.96
|
| Rate for Payer: Cash Price |
$3,609.60
|
| Rate for Payer: Cigna Commercial |
$11,069.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,733.11
|
| Rate for Payer: Health EOS Commercial |
$10,708.48
|
| Rate for Payer: HFN Commercial |
$11,069.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,024.00
|
| Rate for Payer: Multiplan Commercial |
$9,625.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,219.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,069.44
|
| Rate for Payer: Quartz Beloit One Network |
$5,895.68
|
| Rate for Payer: Quartz Commercial |
$7,820.80
|
| Rate for Payer: Quartz Medicare Advantage |
$7,219.20
|
| Rate for Payer: The Alliance Commercial |
$48,128.00
|
| Rate for Payer: WEA Trust Commercial |
$6,617.60
|
| Rate for Payer: WPS Commercial |
$8,912.10
|
|
|
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 |
$5,895.68 |
| Max. Negotiated Rate |
$11,069.44 |
| Rate for Payer: Aetna Commercial |
$10,828.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,347.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,376.96
|
| Rate for Payer: Cash Price |
$3,609.60
|
| Rate for Payer: Cigna Commercial |
$11,069.44
|
| Rate for Payer: Health EOS Commercial |
$10,708.48
|
| Rate for Payer: HFN Commercial |
$11,069.44
|
| Rate for Payer: Multiplan Commercial |
$9,625.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,219.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,069.44
|
| Rate for Payer: Quartz Beloit One Network |
$5,895.68
|
| Rate for Payer: Quartz Commercial |
$7,219.20
|
| Rate for Payer: WEA Trust Commercial |
$6,617.60
|
| Rate for Payer: WPS Commercial |
$8,912.10
|
|
|
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 |
$5,677.14 |
| 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 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 |
$3,244.08 |
| 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
|
|
