|
STEM CENTRALIZER CEMENTRALIZER 11.0MM CEMENTED 1376-20-000
|
Facility
|
OP
|
$1,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$392.54 |
| Max. Negotiated Rate |
$1,289.77 |
| Rate for Payer: Aetna Commercial |
$1,261.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,205.65
|
| Rate for Payer: Aetna Managed Medicare |
$392.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$911.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$700.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$672.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$743.02
|
| Rate for Payer: Cash Price |
$404.40
|
| Rate for Payer: Cigna Commercial |
$1,289.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$784.54
|
| Rate for Payer: Health EOS Commercial |
$1,247.71
|
| Rate for Payer: HFN Commercial |
$1,289.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,051.44
|
| Rate for Payer: Multiplan Commercial |
$1,121.54
|
| Rate for Payer: NAPHCARE Commercial |
$841.15
|
| Rate for Payer: Preferred Network Access Commercial |
$1,289.77
|
| Rate for Payer: Quartz Beloit One Network |
$686.94
|
| Rate for Payer: Quartz Commercial |
$911.25
|
| Rate for Payer: Quartz Medicare Advantage |
$841.15
|
| Rate for Payer: The Alliance Commercial |
$700.96
|
| Rate for Payer: WEA Trust Commercial |
$771.06
|
| Rate for Payer: WPS Commercial |
$1,038.36
|
|
|
STEM CENTRALIZER CEMENTRALIZER 11.0MM CEMENTED 1376-20-000
|
Facility
|
IP
|
$1,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$686.94 |
| Max. Negotiated Rate |
$1,289.77 |
| Rate for Payer: Aetna Commercial |
$1,261.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,205.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$743.02
|
| Rate for Payer: Cash Price |
$404.40
|
| Rate for Payer: Cigna Commercial |
$1,289.77
|
| Rate for Payer: Health EOS Commercial |
$1,247.71
|
| Rate for Payer: HFN Commercial |
$1,289.77
|
| Rate for Payer: Multiplan Commercial |
$1,121.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,289.77
|
| Rate for Payer: Quartz Beloit One Network |
$686.94
|
| Rate for Payer: Quartz Commercial |
$841.15
|
| Rate for Payer: WEA Trust Commercial |
$771.06
|
| Rate for Payer: WPS Commercial |
$1,038.36
|
|
|
STEM CENTRALIZER CEMENTRALIZER 12.0.MM CEMENTED 1376-21-000
|
Facility
|
IP
|
$1,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520921
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$818.42 |
| Max. Negotiated Rate |
$1,536.62 |
| Rate for Payer: Aetna Commercial |
$1,503.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,436.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$885.23
|
| Rate for Payer: Cash Price |
$481.80
|
| Rate for Payer: Cigna Commercial |
$1,536.62
|
| Rate for Payer: Health EOS Commercial |
$1,486.51
|
| Rate for Payer: HFN Commercial |
$1,536.62
|
| Rate for Payer: Multiplan Commercial |
$1,336.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,536.62
|
| Rate for Payer: Quartz Beloit One Network |
$818.42
|
| Rate for Payer: Quartz Commercial |
$1,002.14
|
| Rate for Payer: WEA Trust Commercial |
$918.63
|
| Rate for Payer: WPS Commercial |
$1,237.10
|
|
|
STEM CENTRALIZER CEMENTRALIZER 12.0.MM CEMENTED 1376-21-000
|
Facility
|
OP
|
$1,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520921
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$467.67 |
| Max. Negotiated Rate |
$1,536.62 |
| Rate for Payer: Aetna Commercial |
$1,503.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,436.41
|
| Rate for Payer: Aetna Managed Medicare |
$467.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,085.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$835.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$801.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$885.23
|
| Rate for Payer: Cash Price |
$481.80
|
| Rate for Payer: Cigna Commercial |
$1,536.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$934.69
|
| Rate for Payer: Health EOS Commercial |
$1,486.51
|
| Rate for Payer: HFN Commercial |
$1,536.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,252.68
|
| Rate for Payer: Multiplan Commercial |
$1,336.19
|
| Rate for Payer: NAPHCARE Commercial |
$1,002.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,536.62
|
| Rate for Payer: Quartz Beloit One Network |
$818.42
|
| Rate for Payer: Quartz Commercial |
$1,085.66
|
| Rate for Payer: Quartz Medicare Advantage |
$1,002.14
|
| Rate for Payer: The Alliance Commercial |
$835.12
|
| Rate for Payer: WEA Trust Commercial |
$918.63
|
| Rate for Payer: WPS Commercial |
$1,237.10
|
|
|
STEM CENTRALIZER CEMENTRALIZER 13.0MM CEMENTED 1376-22-000
|
Facility
|
OP
|
$1,198.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6202964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$348.86 |
| Max. Negotiated Rate |
$1,146.25 |
| Rate for Payer: Aetna Commercial |
$1,121.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,071.49
|
| Rate for Payer: Aetna Managed Medicare |
$348.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$809.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$622.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$598.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$660.34
|
| Rate for Payer: Cash Price |
$359.40
|
| Rate for Payer: Cigna Commercial |
$1,146.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$697.24
|
| Rate for Payer: Health EOS Commercial |
$1,108.87
|
| Rate for Payer: HFN Commercial |
$1,146.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.44
|
| Rate for Payer: Multiplan Commercial |
$996.74
|
| Rate for Payer: NAPHCARE Commercial |
$747.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,146.25
|
| Rate for Payer: Quartz Beloit One Network |
$610.50
|
| Rate for Payer: Quartz Commercial |
$809.85
|
| Rate for Payer: Quartz Medicare Advantage |
$747.55
|
| Rate for Payer: The Alliance Commercial |
$622.96
|
| Rate for Payer: WEA Trust Commercial |
$685.26
|
| Rate for Payer: WPS Commercial |
$922.82
|
|
|
STEM CENTRALIZER CEMENTRALIZER 13.0MM CEMENTED 1376-22-000
|
Facility
|
IP
|
$1,198.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6202964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$610.50 |
| Max. Negotiated Rate |
$1,146.25 |
| Rate for Payer: Aetna Commercial |
$1,121.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,071.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$660.34
|
| Rate for Payer: Cash Price |
$359.40
|
| Rate for Payer: Cigna Commercial |
$1,146.25
|
| Rate for Payer: Health EOS Commercial |
$1,108.87
|
| Rate for Payer: HFN Commercial |
$1,146.25
|
| Rate for Payer: Multiplan Commercial |
$996.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,146.25
|
| Rate for Payer: Quartz Beloit One Network |
$610.50
|
| Rate for Payer: Quartz Commercial |
$747.55
|
| Rate for Payer: WEA Trust Commercial |
$685.26
|
| Rate for Payer: WPS Commercial |
$922.82
|
|
|
STEM CENTRALIZER CEMENTRALIZER 8.5MM CEMENTED 1376-46-000
|
Facility
|
OP
|
$1,544.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$449.61 |
| Max. Negotiated Rate |
$1,477.30 |
| Rate for Payer: Aetna Commercial |
$1,445.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,380.95
|
| Rate for Payer: Aetna Managed Medicare |
$449.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,043.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$802.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$770.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$851.05
|
| Rate for Payer: Cash Price |
$463.20
|
| Rate for Payer: Cigna Commercial |
$1,477.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$898.61
|
| Rate for Payer: Health EOS Commercial |
$1,429.13
|
| Rate for Payer: HFN Commercial |
$1,477.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,204.32
|
| Rate for Payer: Multiplan Commercial |
$1,284.61
|
| Rate for Payer: NAPHCARE Commercial |
$963.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,477.30
|
| Rate for Payer: Quartz Beloit One Network |
$786.82
|
| Rate for Payer: Quartz Commercial |
$1,043.74
|
| Rate for Payer: Quartz Medicare Advantage |
$963.46
|
| Rate for Payer: The Alliance Commercial |
$802.88
|
| Rate for Payer: WEA Trust Commercial |
$883.17
|
| Rate for Payer: WPS Commercial |
$1,189.34
|
|
|
STEM CENTRALIZER CEMENTRALIZER 8.5MM CEMENTED 1376-46-000
|
Facility
|
IP
|
$1,544.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$786.82 |
| Max. Negotiated Rate |
$1,477.30 |
| Rate for Payer: Aetna Commercial |
$1,445.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,380.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$851.05
|
| Rate for Payer: Cash Price |
$463.20
|
| Rate for Payer: Cigna Commercial |
$1,477.30
|
| Rate for Payer: Health EOS Commercial |
$1,429.13
|
| Rate for Payer: HFN Commercial |
$1,477.30
|
| Rate for Payer: Multiplan Commercial |
$1,284.61
|
| Rate for Payer: Preferred Network Access Commercial |
$1,477.30
|
| Rate for Payer: Quartz Beloit One Network |
$786.82
|
| Rate for Payer: Quartz Commercial |
$963.46
|
| Rate for Payer: WEA Trust Commercial |
$883.17
|
| Rate for Payer: WPS Commercial |
$1,189.34
|
|
|
STEM CENTRALIZER CEMENTRALIZER 9.25MM CEMENTED 1376-47-000
|
Facility
|
IP
|
$1,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5490784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$818.42 |
| Max. Negotiated Rate |
$1,536.62 |
| Rate for Payer: Aetna Commercial |
$1,503.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,436.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$885.23
|
| Rate for Payer: Cash Price |
$481.80
|
| Rate for Payer: Cigna Commercial |
$1,536.62
|
| Rate for Payer: Health EOS Commercial |
$1,486.51
|
| Rate for Payer: HFN Commercial |
$1,536.62
|
| Rate for Payer: Multiplan Commercial |
$1,336.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,536.62
|
| Rate for Payer: Quartz Beloit One Network |
$818.42
|
| Rate for Payer: Quartz Commercial |
$1,002.14
|
| Rate for Payer: WEA Trust Commercial |
$918.63
|
| Rate for Payer: WPS Commercial |
$1,237.10
|
|
|
STEM CENTRALIZER CEMENTRALIZER 9.25MM CEMENTED 1376-47-000
|
Facility
|
OP
|
$1,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5490784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$467.67 |
| Max. Negotiated Rate |
$1,536.62 |
| Rate for Payer: Aetna Commercial |
$1,503.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,436.41
|
| Rate for Payer: Aetna Managed Medicare |
$467.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,085.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$835.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$801.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$885.23
|
| Rate for Payer: Cash Price |
$481.80
|
| Rate for Payer: Cigna Commercial |
$1,536.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$934.69
|
| Rate for Payer: Health EOS Commercial |
$1,486.51
|
| Rate for Payer: HFN Commercial |
$1,536.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,252.68
|
| Rate for Payer: Multiplan Commercial |
$1,336.19
|
| Rate for Payer: NAPHCARE Commercial |
$1,002.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,536.62
|
| Rate for Payer: Quartz Beloit One Network |
$818.42
|
| Rate for Payer: Quartz Commercial |
$1,085.66
|
| Rate for Payer: Quartz Medicare Advantage |
$1,002.14
|
| Rate for Payer: The Alliance Commercial |
$835.12
|
| Rate for Payer: WEA Trust Commercial |
$918.63
|
| Rate for Payer: WPS Commercial |
$1,237.10
|
|
|
STEM EXTEN 45MM DROP DOWN 5950-067-45
|
Facility
|
IP
|
$4,701.00
|
|
| Hospital Charge Code |
2967858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,395.63 |
| Max. Negotiated Rate |
$4,497.92 |
| Rate for Payer: Aetna Commercial |
$4,400.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,204.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,591.19
|
| Rate for Payer: Cash Price |
$1,410.30
|
| Rate for Payer: Cigna Commercial |
$4,497.92
|
| Rate for Payer: Health EOS Commercial |
$4,351.25
|
| Rate for Payer: HFN Commercial |
$4,497.92
|
| Rate for Payer: Multiplan Commercial |
$3,911.23
|
| Rate for Payer: Preferred Network Access Commercial |
$4,497.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,395.63
|
| Rate for Payer: Quartz Commercial |
$2,933.42
|
| Rate for Payer: WEA Trust Commercial |
$2,688.97
|
| Rate for Payer: WPS Commercial |
$3,621.18
|
|
|
STEM EXTEN 45MM DROP DOWN 5950-067-45
|
Facility
|
OP
|
$4,701.00
|
|
| Hospital Charge Code |
2967858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,368.93 |
| Max. Negotiated Rate |
$4,497.92 |
| Rate for Payer: Aetna Commercial |
$4,400.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,204.57
|
| Rate for Payer: Aetna Managed Medicare |
$1,368.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,177.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,444.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,346.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,591.19
|
| Rate for Payer: Cash Price |
$1,410.30
|
| Rate for Payer: Cigna Commercial |
$4,497.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,735.98
|
| Rate for Payer: Health EOS Commercial |
$4,351.25
|
| Rate for Payer: HFN Commercial |
$4,497.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,666.78
|
| Rate for Payer: Multiplan Commercial |
$3,911.23
|
| Rate for Payer: NAPHCARE Commercial |
$2,933.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,497.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,395.63
|
| Rate for Payer: Quartz Commercial |
$3,177.88
|
| Rate for Payer: Quartz Medicare Advantage |
$2,933.42
|
| Rate for Payer: The Alliance Commercial |
$2,444.52
|
| Rate for Payer: WEA Trust Commercial |
$2,688.97
|
| Rate for Payer: WPS Commercial |
$3,621.18
|
|
|
STEM EXTEN 75MM DROP DOWN 5950-67-75
|
Facility
|
IP
|
$4,701.00
|
|
| Hospital Charge Code |
2967859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,395.63 |
| Max. Negotiated Rate |
$4,497.92 |
| Rate for Payer: Aetna Commercial |
$4,400.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,204.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,591.19
|
| Rate for Payer: Cash Price |
$1,410.30
|
| Rate for Payer: Cigna Commercial |
$4,497.92
|
| Rate for Payer: Health EOS Commercial |
$4,351.25
|
| Rate for Payer: HFN Commercial |
$4,497.92
|
| Rate for Payer: Multiplan Commercial |
$3,911.23
|
| Rate for Payer: Preferred Network Access Commercial |
$4,497.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,395.63
|
| Rate for Payer: Quartz Commercial |
$2,933.42
|
| Rate for Payer: WEA Trust Commercial |
$2,688.97
|
| Rate for Payer: WPS Commercial |
$3,621.18
|
|
|
STEM EXTEN 75MM DROP DOWN 5950-67-75
|
Facility
|
OP
|
$4,701.00
|
|
| Hospital Charge Code |
2967859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,368.93 |
| Max. Negotiated Rate |
$4,497.92 |
| Rate for Payer: Aetna Commercial |
$4,400.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,204.57
|
| Rate for Payer: Aetna Managed Medicare |
$1,368.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,177.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,444.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,346.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,591.19
|
| Rate for Payer: Cash Price |
$1,410.30
|
| Rate for Payer: Cigna Commercial |
$4,497.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,735.98
|
| Rate for Payer: Health EOS Commercial |
$4,351.25
|
| Rate for Payer: HFN Commercial |
$4,497.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,666.78
|
| Rate for Payer: Multiplan Commercial |
$3,911.23
|
| Rate for Payer: NAPHCARE Commercial |
$2,933.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,497.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,395.63
|
| Rate for Payer: Quartz Commercial |
$3,177.88
|
| Rate for Payer: Quartz Medicare Advantage |
$2,933.42
|
| Rate for Payer: The Alliance Commercial |
$2,444.52
|
| Rate for Payer: WEA Trust Commercial |
$2,688.97
|
| Rate for Payer: WPS Commercial |
$3,621.18
|
|
|
STEM EXTENSION 12m x 100mm
|
Facility
|
IP
|
$7,810.00
|
|
| Hospital Charge Code |
2967533
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,979.98 |
| Max. Negotiated Rate |
$7,472.61 |
| Rate for Payer: Aetna Commercial |
$7,310.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,985.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,304.87
|
| Rate for Payer: Cash Price |
$2,343.00
|
| Rate for Payer: Cigna Commercial |
$7,472.61
|
| Rate for Payer: Health EOS Commercial |
$7,228.94
|
| Rate for Payer: HFN Commercial |
$7,472.61
|
| Rate for Payer: Multiplan Commercial |
$6,497.92
|
| Rate for Payer: Preferred Network Access Commercial |
$7,472.61
|
| Rate for Payer: Quartz Beloit One Network |
$3,979.98
|
| Rate for Payer: Quartz Commercial |
$4,873.44
|
| Rate for Payer: WEA Trust Commercial |
$4,467.32
|
| Rate for Payer: WPS Commercial |
$6,016.04
|
|
|
STEM EXTENSION 12m x 100mm
|
Facility
|
OP
|
$7,810.00
|
|
| Hospital Charge Code |
2967533
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,274.27 |
| Max. Negotiated Rate |
$7,472.61 |
| Rate for Payer: Aetna Commercial |
$7,310.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,985.26
|
| Rate for Payer: Aetna Managed Medicare |
$2,274.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,279.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,061.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,898.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,304.87
|
| Rate for Payer: Cash Price |
$2,343.00
|
| Rate for Payer: Cigna Commercial |
$7,472.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,545.42
|
| Rate for Payer: Health EOS Commercial |
$7,228.94
|
| Rate for Payer: HFN Commercial |
$7,472.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,091.80
|
| Rate for Payer: Multiplan Commercial |
$6,497.92
|
| Rate for Payer: NAPHCARE Commercial |
$4,873.44
|
| Rate for Payer: Preferred Network Access Commercial |
$7,472.61
|
| Rate for Payer: Quartz Beloit One Network |
$3,979.98
|
| Rate for Payer: Quartz Commercial |
$5,279.56
|
| Rate for Payer: Quartz Medicare Advantage |
$4,873.44
|
| Rate for Payer: The Alliance Commercial |
$4,061.20
|
| Rate for Payer: WEA Trust Commercial |
$4,467.32
|
| Rate for Payer: WPS Commercial |
$6,016.04
|
|
|
STEM EXTENSION FLUTED 11MM X 75MM 00-5988-015-11
|
Facility
|
IP
|
$5,067.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,582.14 |
| Max. Negotiated Rate |
$4,848.11 |
| Rate for Payer: Aetna Commercial |
$4,742.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,531.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,792.93
|
| Rate for Payer: Cash Price |
$1,520.10
|
| Rate for Payer: Cigna Commercial |
$4,848.11
|
| Rate for Payer: Health EOS Commercial |
$4,690.02
|
| Rate for Payer: HFN Commercial |
$4,848.11
|
| Rate for Payer: Multiplan Commercial |
$4,215.74
|
| Rate for Payer: Preferred Network Access Commercial |
$4,848.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,582.14
|
| Rate for Payer: Quartz Commercial |
$3,161.81
|
| Rate for Payer: WEA Trust Commercial |
$2,898.32
|
| Rate for Payer: WPS Commercial |
$3,903.11
|
|
|
STEM EXTENSION FLUTED 11MM X 75MM 00-5988-015-11
|
Facility
|
OP
|
$5,067.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,475.51 |
| Max. Negotiated Rate |
$4,848.11 |
| Rate for Payer: Aetna Commercial |
$4,742.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,531.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,475.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,425.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,634.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,529.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,792.93
|
| Rate for Payer: Cash Price |
$1,520.10
|
| Rate for Payer: Cigna Commercial |
$4,848.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,948.99
|
| Rate for Payer: Health EOS Commercial |
$4,690.02
|
| Rate for Payer: HFN Commercial |
$4,848.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,952.26
|
| Rate for Payer: Multiplan Commercial |
$4,215.74
|
| Rate for Payer: NAPHCARE Commercial |
$3,161.81
|
| Rate for Payer: Preferred Network Access Commercial |
$4,848.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,582.14
|
| Rate for Payer: Quartz Commercial |
$3,425.29
|
| Rate for Payer: Quartz Medicare Advantage |
$3,161.81
|
| Rate for Payer: The Alliance Commercial |
$2,634.84
|
| Rate for Payer: WEA Trust Commercial |
$2,898.32
|
| Rate for Payer: WPS Commercial |
$3,903.11
|
|
|
STEM EXTENSION FLUTED 13MM X 130MM 00-5988-016-13
|
Facility
|
OP
|
$5,067.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,475.51 |
| Max. Negotiated Rate |
$4,848.11 |
| Rate for Payer: Aetna Commercial |
$4,742.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,531.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,475.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,425.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,634.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,529.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,792.93
|
| Rate for Payer: Cash Price |
$1,520.10
|
| Rate for Payer: Cigna Commercial |
$4,848.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,948.99
|
| Rate for Payer: Health EOS Commercial |
$4,690.02
|
| Rate for Payer: HFN Commercial |
$4,848.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,952.26
|
| Rate for Payer: Multiplan Commercial |
$4,215.74
|
| Rate for Payer: NAPHCARE Commercial |
$3,161.81
|
| Rate for Payer: Preferred Network Access Commercial |
$4,848.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,582.14
|
| Rate for Payer: Quartz Commercial |
$3,425.29
|
| Rate for Payer: Quartz Medicare Advantage |
$3,161.81
|
| Rate for Payer: The Alliance Commercial |
$2,634.84
|
| Rate for Payer: WEA Trust Commercial |
$2,898.32
|
| Rate for Payer: WPS Commercial |
$3,903.11
|
|
|
STEM EXTENSION FLUTED 13MM X 130MM 00-5988-016-13
|
Facility
|
IP
|
$5,067.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,582.14 |
| Max. Negotiated Rate |
$4,848.11 |
| Rate for Payer: Aetna Commercial |
$4,742.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,531.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,792.93
|
| Rate for Payer: Cash Price |
$1,520.10
|
| Rate for Payer: Cigna Commercial |
$4,848.11
|
| Rate for Payer: Health EOS Commercial |
$4,690.02
|
| Rate for Payer: HFN Commercial |
$4,848.11
|
| Rate for Payer: Multiplan Commercial |
$4,215.74
|
| Rate for Payer: Preferred Network Access Commercial |
$4,848.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,582.14
|
| Rate for Payer: Quartz Commercial |
$3,161.81
|
| Rate for Payer: WEA Trust Commercial |
$2,898.32
|
| Rate for Payer: WPS Commercial |
$3,903.11
|
|
|
STEM EXTENSION OFFSET 11MM X 100MM 5988-20-11
|
Facility
|
IP
|
$7,651.00
|
|
| Hospital Charge Code |
2973971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,898.95 |
| Max. Negotiated Rate |
$7,320.48 |
| Rate for Payer: Aetna Commercial |
$7,161.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,843.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,217.23
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,320.48
|
| Rate for Payer: Health EOS Commercial |
$7,081.77
|
| Rate for Payer: HFN Commercial |
$7,320.48
|
| Rate for Payer: Multiplan Commercial |
$6,365.63
|
| Rate for Payer: Preferred Network Access Commercial |
$7,320.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,898.95
|
| Rate for Payer: Quartz Commercial |
$4,774.22
|
| Rate for Payer: WEA Trust Commercial |
$4,376.37
|
| Rate for Payer: WPS Commercial |
$5,893.57
|
|
|
STEM EXTENSION OFFSET 11MM X 100MM 5988-20-11
|
Facility
|
OP
|
$7,651.00
|
|
| Hospital Charge Code |
2973971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,227.97 |
| Max. Negotiated Rate |
$7,320.48 |
| Rate for Payer: Aetna Commercial |
$7,161.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,843.05
|
| Rate for Payer: Aetna Managed Medicare |
$2,227.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,172.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,978.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,819.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,217.23
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,320.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,452.88
|
| Rate for Payer: Health EOS Commercial |
$7,081.77
|
| Rate for Payer: HFN Commercial |
$7,320.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,967.78
|
| Rate for Payer: Multiplan Commercial |
$6,365.63
|
| Rate for Payer: NAPHCARE Commercial |
$4,774.22
|
| Rate for Payer: Preferred Network Access Commercial |
$7,320.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,898.95
|
| Rate for Payer: Quartz Commercial |
$5,172.08
|
| Rate for Payer: Quartz Medicare Advantage |
$4,774.22
|
| Rate for Payer: The Alliance Commercial |
$3,978.52
|
| Rate for Payer: WEA Trust Commercial |
$4,376.37
|
| Rate for Payer: WPS Commercial |
$5,893.57
|
|
|
STEM EXTENSION OFFSET 13MM X 100MM 5988-20-13
|
Facility
|
IP
|
$7,651.00
|
|
| Hospital Charge Code |
2973977
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,898.95 |
| Max. Negotiated Rate |
$7,320.48 |
| Rate for Payer: Aetna Commercial |
$7,161.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,843.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,217.23
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,320.48
|
| Rate for Payer: Health EOS Commercial |
$7,081.77
|
| Rate for Payer: HFN Commercial |
$7,320.48
|
| Rate for Payer: Multiplan Commercial |
$6,365.63
|
| Rate for Payer: Preferred Network Access Commercial |
$7,320.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,898.95
|
| Rate for Payer: Quartz Commercial |
$4,774.22
|
| Rate for Payer: WEA Trust Commercial |
$4,376.37
|
| Rate for Payer: WPS Commercial |
$5,893.57
|
|
|
STEM EXTENSION OFFSET 13MM X 100MM 5988-20-13
|
Facility
|
OP
|
$7,651.00
|
|
| Hospital Charge Code |
2973977
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,227.97 |
| Max. Negotiated Rate |
$7,320.48 |
| Rate for Payer: Aetna Commercial |
$7,161.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,843.05
|
| Rate for Payer: Aetna Managed Medicare |
$2,227.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,172.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,978.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,819.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,217.23
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,320.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,452.88
|
| Rate for Payer: Health EOS Commercial |
$7,081.77
|
| Rate for Payer: HFN Commercial |
$7,320.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,967.78
|
| Rate for Payer: Multiplan Commercial |
$6,365.63
|
| Rate for Payer: NAPHCARE Commercial |
$4,774.22
|
| Rate for Payer: Preferred Network Access Commercial |
$7,320.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,898.95
|
| Rate for Payer: Quartz Commercial |
$5,172.08
|
| Rate for Payer: Quartz Medicare Advantage |
$4,774.22
|
| Rate for Payer: The Alliance Commercial |
$3,978.52
|
| Rate for Payer: WEA Trust Commercial |
$4,376.37
|
| Rate for Payer: WPS Commercial |
$5,893.57
|
|
|
STEM EXTENSION OFFSET 15MM X 100MM 5988-20-15
|
Facility
|
OP
|
$7,651.00
|
|
| Hospital Charge Code |
2973972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,227.97 |
| Max. Negotiated Rate |
$7,320.48 |
| Rate for Payer: Aetna Commercial |
$7,161.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,843.05
|
| Rate for Payer: Aetna Managed Medicare |
$2,227.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,172.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,978.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,819.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,217.23
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,320.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,452.88
|
| Rate for Payer: Health EOS Commercial |
$7,081.77
|
| Rate for Payer: HFN Commercial |
$7,320.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,967.78
|
| Rate for Payer: Multiplan Commercial |
$6,365.63
|
| Rate for Payer: NAPHCARE Commercial |
$4,774.22
|
| Rate for Payer: Preferred Network Access Commercial |
$7,320.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,898.95
|
| Rate for Payer: Quartz Commercial |
$5,172.08
|
| Rate for Payer: Quartz Medicare Advantage |
$4,774.22
|
| Rate for Payer: The Alliance Commercial |
$3,978.52
|
| Rate for Payer: WEA Trust Commercial |
$4,376.37
|
| Rate for Payer: WPS Commercial |
$5,893.57
|
|
