|
STEM REVISION CEMENTED ATTUNE 14MM X 50MM 1512-14-050
|
Facility
|
OP
|
$4,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6165879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,438.53 |
| Max. Negotiated Rate |
$4,726.59 |
| Rate for Payer: Aetna Commercial |
$4,623.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,418.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,438.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,339.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,568.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,466.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,722.93
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$4,726.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,875.08
|
| Rate for Payer: Health EOS Commercial |
$4,572.46
|
| Rate for Payer: HFN Commercial |
$4,726.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,853.20
|
| Rate for Payer: Multiplan Commercial |
$4,110.08
|
| Rate for Payer: NAPHCARE Commercial |
$3,082.56
|
| Rate for Payer: Preferred Network Access Commercial |
$4,726.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,517.42
|
| Rate for Payer: Quartz Commercial |
$3,339.44
|
| Rate for Payer: Quartz Medicare Advantage |
$3,082.56
|
| Rate for Payer: The Alliance Commercial |
$2,568.80
|
| Rate for Payer: WEA Trust Commercial |
$2,825.68
|
| Rate for Payer: WPS Commercial |
$3,805.28
|
|
|
STEM REVISION CEMENTED ATTUNE 14MM X 50MM 1512-14-050
|
Facility
|
IP
|
$4,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6165879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,517.42 |
| Max. Negotiated Rate |
$4,726.59 |
| Rate for Payer: Aetna Commercial |
$4,623.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,418.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,722.93
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$4,726.59
|
| Rate for Payer: Health EOS Commercial |
$4,572.46
|
| Rate for Payer: HFN Commercial |
$4,726.59
|
| Rate for Payer: Multiplan Commercial |
$4,110.08
|
| Rate for Payer: Preferred Network Access Commercial |
$4,726.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,517.42
|
| Rate for Payer: Quartz Commercial |
$3,082.56
|
| Rate for Payer: WEA Trust Commercial |
$2,825.68
|
| Rate for Payer: WPS Commercial |
$3,805.28
|
|
|
STEM REVISION CEMENTED ATTUNE 14MM X 80MM 1512-14-080
|
Facility
|
IP
|
$7,862.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,006.48 |
| Max. Negotiated Rate |
$7,522.36 |
| Rate for Payer: Aetna Commercial |
$7,358.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,031.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,333.53
|
| Rate for Payer: Cash Price |
$2,358.60
|
| Rate for Payer: Cigna Commercial |
$7,522.36
|
| Rate for Payer: Health EOS Commercial |
$7,277.07
|
| Rate for Payer: HFN Commercial |
$7,522.36
|
| Rate for Payer: Multiplan Commercial |
$6,541.18
|
| Rate for Payer: Preferred Network Access Commercial |
$7,522.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,006.48
|
| Rate for Payer: Quartz Commercial |
$4,905.89
|
| Rate for Payer: WEA Trust Commercial |
$4,497.06
|
| Rate for Payer: WPS Commercial |
$6,056.10
|
|
|
STEM REVISION CEMENTED ATTUNE 14MM X 80MM 1512-14-080
|
Facility
|
OP
|
$7,862.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,289.41 |
| Max. Negotiated Rate |
$7,522.36 |
| Rate for Payer: Aetna Commercial |
$7,358.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,031.77
|
| Rate for Payer: Aetna Managed Medicare |
$2,289.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,314.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,088.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,924.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,333.53
|
| Rate for Payer: Cash Price |
$2,358.60
|
| Rate for Payer: Cigna Commercial |
$7,522.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,575.68
|
| Rate for Payer: Health EOS Commercial |
$7,277.07
|
| Rate for Payer: HFN Commercial |
$7,522.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,132.36
|
| Rate for Payer: Multiplan Commercial |
$6,541.18
|
| Rate for Payer: NAPHCARE Commercial |
$4,905.89
|
| Rate for Payer: Preferred Network Access Commercial |
$7,522.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,006.48
|
| Rate for Payer: Quartz Commercial |
$5,314.71
|
| Rate for Payer: Quartz Medicare Advantage |
$4,905.89
|
| Rate for Payer: The Alliance Commercial |
$4,088.24
|
| Rate for Payer: WEA Trust Commercial |
$4,497.06
|
| Rate for Payer: WPS Commercial |
$6,056.10
|
|
|
STEM REVISION PRESSFIT ATTUNE 12MM X 60MM 1513-12-060
|
Facility
|
IP
|
$7,943.03
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6244178
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,047.77 |
| Max. Negotiated Rate |
$7,599.89 |
| Rate for Payer: Aetna Commercial |
$7,434.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,104.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,378.20
|
| Rate for Payer: Cash Price |
$2,382.91
|
| Rate for Payer: Cigna Commercial |
$7,599.89
|
| Rate for Payer: Health EOS Commercial |
$7,352.07
|
| Rate for Payer: HFN Commercial |
$7,599.89
|
| Rate for Payer: Multiplan Commercial |
$6,608.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,599.89
|
| Rate for Payer: Quartz Beloit One Network |
$4,047.77
|
| Rate for Payer: Quartz Commercial |
$4,956.45
|
| Rate for Payer: WEA Trust Commercial |
$4,543.41
|
| Rate for Payer: WPS Commercial |
$6,118.52
|
|
|
STEM REVISION PRESSFIT ATTUNE 12MM X 60MM 1513-12-060
|
Facility
|
OP
|
$7,943.03
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6244178
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,313.01 |
| Max. Negotiated Rate |
$7,599.89 |
| Rate for Payer: Aetna Commercial |
$7,434.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,104.25
|
| Rate for Payer: Aetna Managed Medicare |
$2,313.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,369.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,130.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,965.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,378.20
|
| Rate for Payer: Cash Price |
$2,382.91
|
| Rate for Payer: Cigna Commercial |
$7,599.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,622.84
|
| Rate for Payer: Health EOS Commercial |
$7,352.07
|
| Rate for Payer: HFN Commercial |
$7,599.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,195.56
|
| Rate for Payer: Multiplan Commercial |
$6,608.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,956.45
|
| Rate for Payer: Preferred Network Access Commercial |
$7,599.89
|
| Rate for Payer: Quartz Beloit One Network |
$4,047.77
|
| Rate for Payer: Quartz Commercial |
$5,369.49
|
| Rate for Payer: Quartz Medicare Advantage |
$4,956.45
|
| Rate for Payer: The Alliance Commercial |
$4,130.38
|
| Rate for Payer: WEA Trust Commercial |
$4,543.41
|
| Rate for Payer: WPS Commercial |
$6,118.52
|
|
|
STEM REVISION PRESSFIT ATTUNE 14MM X 110MM 1513-14-110
|
Facility
|
OP
|
$8,444.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,458.89 |
| Max. Negotiated Rate |
$8,079.22 |
| Rate for Payer: Aetna Commercial |
$7,903.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,552.31
|
| Rate for Payer: Aetna Managed Medicare |
$2,458.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,708.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,390.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,215.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,654.33
|
| Rate for Payer: Cash Price |
$2,533.20
|
| Rate for Payer: Cigna Commercial |
$8,079.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,914.41
|
| Rate for Payer: Health EOS Commercial |
$7,815.77
|
| Rate for Payer: HFN Commercial |
$8,079.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,586.32
|
| Rate for Payer: Multiplan Commercial |
$7,025.41
|
| Rate for Payer: NAPHCARE Commercial |
$5,269.06
|
| Rate for Payer: Preferred Network Access Commercial |
$8,079.22
|
| Rate for Payer: Quartz Beloit One Network |
$4,303.06
|
| Rate for Payer: Quartz Commercial |
$5,708.14
|
| Rate for Payer: Quartz Medicare Advantage |
$5,269.06
|
| Rate for Payer: The Alliance Commercial |
$4,390.88
|
| Rate for Payer: WEA Trust Commercial |
$4,829.97
|
| Rate for Payer: WPS Commercial |
$6,504.41
|
|
|
STEM REVISION PRESSFIT ATTUNE 14MM X 110MM 1513-14-110
|
Facility
|
IP
|
$8,444.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,303.06 |
| Max. Negotiated Rate |
$8,079.22 |
| Rate for Payer: Aetna Commercial |
$7,903.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,552.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,654.33
|
| Rate for Payer: Cash Price |
$2,533.20
|
| Rate for Payer: Cigna Commercial |
$8,079.22
|
| Rate for Payer: Health EOS Commercial |
$7,815.77
|
| Rate for Payer: HFN Commercial |
$8,079.22
|
| Rate for Payer: Multiplan Commercial |
$7,025.41
|
| Rate for Payer: Preferred Network Access Commercial |
$8,079.22
|
| Rate for Payer: Quartz Beloit One Network |
$4,303.06
|
| Rate for Payer: Quartz Commercial |
$5,269.06
|
| Rate for Payer: WEA Trust Commercial |
$4,829.97
|
| Rate for Payer: WPS Commercial |
$6,504.41
|
|
|
STEM REVISION PRESSFIT ATTUNE 14MM X 60MM 1513-14-060
|
Facility
|
OP
|
$12,426.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,618.45 |
| Max. Negotiated Rate |
$11,889.20 |
| Rate for Payer: Aetna Commercial |
$11,630.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,113.81
|
| Rate for Payer: Aetna Managed Medicare |
$3,618.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,399.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,461.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,203.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,849.21
|
| Rate for Payer: Cash Price |
$3,727.80
|
| Rate for Payer: Cigna Commercial |
$11,889.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,231.93
|
| Rate for Payer: Health EOS Commercial |
$11,501.51
|
| Rate for Payer: HFN Commercial |
$11,889.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,692.28
|
| Rate for Payer: Multiplan Commercial |
$10,338.43
|
| Rate for Payer: NAPHCARE Commercial |
$7,753.82
|
| Rate for Payer: Preferred Network Access Commercial |
$11,889.20
|
| Rate for Payer: Quartz Beloit One Network |
$6,332.29
|
| Rate for Payer: Quartz Commercial |
$8,399.98
|
| Rate for Payer: Quartz Medicare Advantage |
$7,753.82
|
| Rate for Payer: The Alliance Commercial |
$6,461.52
|
| Rate for Payer: WEA Trust Commercial |
$7,107.67
|
| Rate for Payer: WPS Commercial |
$9,571.75
|
|
|
STEM REVISION PRESSFIT ATTUNE 14MM X 60MM 1513-14-060
|
Facility
|
IP
|
$12,426.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,332.29 |
| Max. Negotiated Rate |
$11,889.20 |
| Rate for Payer: Aetna Commercial |
$11,630.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,113.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,849.21
|
| Rate for Payer: Cash Price |
$3,727.80
|
| Rate for Payer: Cigna Commercial |
$11,889.20
|
| Rate for Payer: Health EOS Commercial |
$11,501.51
|
| Rate for Payer: HFN Commercial |
$11,889.20
|
| Rate for Payer: Multiplan Commercial |
$10,338.43
|
| Rate for Payer: Preferred Network Access Commercial |
$11,889.20
|
| Rate for Payer: Quartz Beloit One Network |
$6,332.29
|
| Rate for Payer: Quartz Commercial |
$7,753.82
|
| Rate for Payer: WEA Trust Commercial |
$7,107.67
|
| Rate for Payer: WPS Commercial |
$9,571.75
|
|
|
STEM REVISION PRESSFIT ATTUNE 16MM X 60MM 1513-16-060
|
Facility
|
OP
|
$12,426.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528744
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,618.45 |
| Max. Negotiated Rate |
$11,889.20 |
| Rate for Payer: Aetna Commercial |
$11,630.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,113.81
|
| Rate for Payer: Aetna Managed Medicare |
$3,618.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,399.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,461.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,203.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,849.21
|
| Rate for Payer: Cash Price |
$3,727.80
|
| Rate for Payer: Cigna Commercial |
$11,889.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,231.93
|
| Rate for Payer: Health EOS Commercial |
$11,501.51
|
| Rate for Payer: HFN Commercial |
$11,889.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,692.28
|
| Rate for Payer: Multiplan Commercial |
$10,338.43
|
| Rate for Payer: NAPHCARE Commercial |
$7,753.82
|
| Rate for Payer: Preferred Network Access Commercial |
$11,889.20
|
| Rate for Payer: Quartz Beloit One Network |
$6,332.29
|
| Rate for Payer: Quartz Commercial |
$8,399.98
|
| Rate for Payer: Quartz Medicare Advantage |
$7,753.82
|
| Rate for Payer: The Alliance Commercial |
$6,461.52
|
| Rate for Payer: WEA Trust Commercial |
$7,107.67
|
| Rate for Payer: WPS Commercial |
$9,571.75
|
|
|
STEM REVISION PRESSFIT ATTUNE 16MM X 60MM 1513-16-060
|
Facility
|
IP
|
$12,426.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528744
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,332.29 |
| Max. Negotiated Rate |
$11,889.20 |
| Rate for Payer: Aetna Commercial |
$11,630.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,113.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,849.21
|
| Rate for Payer: Cash Price |
$3,727.80
|
| Rate for Payer: Cigna Commercial |
$11,889.20
|
| Rate for Payer: Health EOS Commercial |
$11,501.51
|
| Rate for Payer: HFN Commercial |
$11,889.20
|
| Rate for Payer: Multiplan Commercial |
$10,338.43
|
| Rate for Payer: Preferred Network Access Commercial |
$11,889.20
|
| Rate for Payer: Quartz Beloit One Network |
$6,332.29
|
| Rate for Payer: Quartz Commercial |
$7,753.82
|
| Rate for Payer: WEA Trust Commercial |
$7,107.67
|
| Rate for Payer: WPS Commercial |
$9,571.75
|
|
|
STEM REVISION PRESSFIT ATTUNE 20MM X 110MM 1513-20-110
|
Facility
|
OP
|
$8,119.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.25 |
| Max. Negotiated Rate |
$7,768.26 |
| Rate for Payer: Aetna Commercial |
$7,599.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,261.63
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,488.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,221.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,053.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,475.19
|
| Rate for Payer: Cash Price |
$2,435.70
|
| Rate for Payer: Cigna Commercial |
$7,768.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,725.26
|
| Rate for Payer: Health EOS Commercial |
$7,514.95
|
| Rate for Payer: HFN Commercial |
$7,768.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,332.82
|
| Rate for Payer: Multiplan Commercial |
$6,755.01
|
| Rate for Payer: NAPHCARE Commercial |
$5,066.26
|
| Rate for Payer: Preferred Network Access Commercial |
$7,768.26
|
| Rate for Payer: Quartz Beloit One Network |
$4,137.44
|
| Rate for Payer: Quartz Commercial |
$5,488.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,066.26
|
| Rate for Payer: The Alliance Commercial |
$4,221.88
|
| Rate for Payer: WEA Trust Commercial |
$4,644.07
|
| Rate for Payer: WPS Commercial |
$6,254.07
|
|
|
STEM REVISION PRESSFIT ATTUNE 20MM X 110MM 1513-20-110
|
Facility
|
IP
|
$8,119.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,137.44 |
| Max. Negotiated Rate |
$7,768.26 |
| Rate for Payer: Aetna Commercial |
$7,599.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,261.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,475.19
|
| Rate for Payer: Cash Price |
$2,435.70
|
| Rate for Payer: Cigna Commercial |
$7,768.26
|
| Rate for Payer: Health EOS Commercial |
$7,514.95
|
| Rate for Payer: HFN Commercial |
$7,768.26
|
| Rate for Payer: Multiplan Commercial |
$6,755.01
|
| Rate for Payer: Preferred Network Access Commercial |
$7,768.26
|
| Rate for Payer: Quartz Beloit One Network |
$4,137.44
|
| Rate for Payer: Quartz Commercial |
$5,066.26
|
| Rate for Payer: WEA Trust Commercial |
$4,644.07
|
| Rate for Payer: WPS Commercial |
$6,254.07
|
|
|
STEM STD OFFSE TRABEC 10MM 00-7864-10-00
|
Facility
|
IP
|
$25,164.00
|
|
| Hospital Charge Code |
2967840
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,823.57 |
| Max. Negotiated Rate |
$24,076.92 |
| Rate for Payer: Aetna Commercial |
$23,553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,506.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,870.40
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cigna Commercial |
$24,076.92
|
| Rate for Payer: Health EOS Commercial |
$23,291.80
|
| Rate for Payer: HFN Commercial |
$24,076.92
|
| Rate for Payer: Multiplan Commercial |
$20,936.45
|
| Rate for Payer: Preferred Network Access Commercial |
$24,076.92
|
| Rate for Payer: Quartz Beloit One Network |
$12,823.57
|
| Rate for Payer: Quartz Commercial |
$15,702.34
|
| Rate for Payer: WEA Trust Commercial |
$14,393.81
|
| Rate for Payer: WPS Commercial |
$19,383.83
|
|
|
STEM STD OFFSE TRABEC 10MM 00-7864-10-00
|
Facility
|
OP
|
$25,164.00
|
|
| Hospital Charge Code |
2967840
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,327.76 |
| Max. Negotiated Rate |
$24,076.92 |
| Rate for Payer: Aetna Commercial |
$23,553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,506.68
|
| Rate for Payer: Aetna Managed Medicare |
$7,327.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,010.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,085.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,561.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,870.40
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cigna Commercial |
$24,076.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,645.45
|
| Rate for Payer: Health EOS Commercial |
$23,291.80
|
| Rate for Payer: HFN Commercial |
$24,076.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,627.92
|
| Rate for Payer: Multiplan Commercial |
$20,936.45
|
| Rate for Payer: NAPHCARE Commercial |
$15,702.34
|
| Rate for Payer: Preferred Network Access Commercial |
$24,076.92
|
| Rate for Payer: Quartz Beloit One Network |
$12,823.57
|
| Rate for Payer: Quartz Commercial |
$17,010.86
|
| Rate for Payer: Quartz Medicare Advantage |
$15,702.34
|
| Rate for Payer: The Alliance Commercial |
$13,085.28
|
| Rate for Payer: WEA Trust Commercial |
$14,393.81
|
| Rate for Payer: WPS Commercial |
$19,383.83
|
|
|
STEM STD OFFSE TRABEC 15MM 00-7864-15-00
|
Facility
|
IP
|
$26,131.00
|
|
| Hospital Charge Code |
2967850
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,316.36 |
| Max. Negotiated Rate |
$25,002.14 |
| Rate for Payer: Aetna Commercial |
$24,458.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,371.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,403.41
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$25,002.14
|
| Rate for Payer: Health EOS Commercial |
$24,186.85
|
| Rate for Payer: HFN Commercial |
$25,002.14
|
| Rate for Payer: Multiplan Commercial |
$21,740.99
|
| Rate for Payer: Preferred Network Access Commercial |
$25,002.14
|
| Rate for Payer: Quartz Beloit One Network |
$13,316.36
|
| Rate for Payer: Quartz Commercial |
$16,305.74
|
| Rate for Payer: WEA Trust Commercial |
$14,946.93
|
| Rate for Payer: WPS Commercial |
$20,128.71
|
|
|
STEM STD OFFSE TRABEC 15MM 00-7864-15-00
|
Facility
|
OP
|
$26,131.00
|
|
| Hospital Charge Code |
2967850
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,609.35 |
| Max. Negotiated Rate |
$25,002.14 |
| Rate for Payer: Aetna Commercial |
$24,458.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,371.57
|
| Rate for Payer: Aetna Managed Medicare |
$7,609.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,664.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,588.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,044.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,403.41
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$25,002.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,208.24
|
| Rate for Payer: Health EOS Commercial |
$24,186.85
|
| Rate for Payer: HFN Commercial |
$25,002.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,382.18
|
| Rate for Payer: Multiplan Commercial |
$21,740.99
|
| Rate for Payer: NAPHCARE Commercial |
$16,305.74
|
| Rate for Payer: Preferred Network Access Commercial |
$25,002.14
|
| Rate for Payer: Quartz Beloit One Network |
$13,316.36
|
| Rate for Payer: Quartz Commercial |
$17,664.56
|
| Rate for Payer: Quartz Medicare Advantage |
$16,305.74
|
| Rate for Payer: The Alliance Commercial |
$13,588.12
|
| Rate for Payer: WEA Trust Commercial |
$14,946.93
|
| Rate for Payer: WPS Commercial |
$20,128.71
|
|
|
STEM STD OFFSE TRABEC 16MM 00-7864-016-00
|
Facility
|
OP
|
$25,164.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967852
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,327.76 |
| Max. Negotiated Rate |
$24,076.92 |
| Rate for Payer: Aetna Commercial |
$23,553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,506.68
|
| Rate for Payer: Aetna Managed Medicare |
$7,327.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,010.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,085.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,561.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,870.40
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cigna Commercial |
$24,076.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,645.45
|
| Rate for Payer: Health EOS Commercial |
$23,291.80
|
| Rate for Payer: HFN Commercial |
$24,076.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,627.92
|
| Rate for Payer: Multiplan Commercial |
$20,936.45
|
| Rate for Payer: NAPHCARE Commercial |
$15,702.34
|
| Rate for Payer: Preferred Network Access Commercial |
$24,076.92
|
| Rate for Payer: Quartz Beloit One Network |
$12,823.57
|
| Rate for Payer: Quartz Commercial |
$17,010.86
|
| Rate for Payer: Quartz Medicare Advantage |
$15,702.34
|
| Rate for Payer: The Alliance Commercial |
$13,085.28
|
| Rate for Payer: WEA Trust Commercial |
$14,393.81
|
| Rate for Payer: WPS Commercial |
$19,383.83
|
|
|
STEM STD OFFSE TRABEC 16MM 00-7864-016-00
|
Facility
|
IP
|
$25,164.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967852
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,823.57 |
| Max. Negotiated Rate |
$24,076.92 |
| Rate for Payer: Aetna Commercial |
$23,553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,506.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,870.40
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cigna Commercial |
$24,076.92
|
| Rate for Payer: Health EOS Commercial |
$23,291.80
|
| Rate for Payer: HFN Commercial |
$24,076.92
|
| Rate for Payer: Multiplan Commercial |
$20,936.45
|
| Rate for Payer: Preferred Network Access Commercial |
$24,076.92
|
| Rate for Payer: Quartz Beloit One Network |
$12,823.57
|
| Rate for Payer: Quartz Commercial |
$15,702.34
|
| Rate for Payer: WEA Trust Commercial |
$14,393.81
|
| Rate for Payer: WPS Commercial |
$19,383.83
|
|
|
STEM STD OFFSE TRABEC 17MM 00-7864-017-00
|
Facility
|
IP
|
$25,164.00
|
|
| Hospital Charge Code |
2967854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,823.57 |
| Max. Negotiated Rate |
$24,076.92 |
| Rate for Payer: Aetna Commercial |
$23,553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,506.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,870.40
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cigna Commercial |
$24,076.92
|
| Rate for Payer: Health EOS Commercial |
$23,291.80
|
| Rate for Payer: HFN Commercial |
$24,076.92
|
| Rate for Payer: Multiplan Commercial |
$20,936.45
|
| Rate for Payer: Preferred Network Access Commercial |
$24,076.92
|
| Rate for Payer: Quartz Beloit One Network |
$12,823.57
|
| Rate for Payer: Quartz Commercial |
$15,702.34
|
| Rate for Payer: WEA Trust Commercial |
$14,393.81
|
| Rate for Payer: WPS Commercial |
$19,383.83
|
|
|
STEM STD OFFSE TRABEC 17MM 00-7864-017-00
|
Facility
|
OP
|
$25,164.00
|
|
| Hospital Charge Code |
2967854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,327.76 |
| Max. Negotiated Rate |
$24,076.92 |
| Rate for Payer: Aetna Commercial |
$23,553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,506.68
|
| Rate for Payer: Aetna Managed Medicare |
$7,327.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,010.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,085.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,561.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,870.40
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cigna Commercial |
$24,076.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,645.45
|
| Rate for Payer: Health EOS Commercial |
$23,291.80
|
| Rate for Payer: HFN Commercial |
$24,076.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,627.92
|
| Rate for Payer: Multiplan Commercial |
$20,936.45
|
| Rate for Payer: NAPHCARE Commercial |
$15,702.34
|
| Rate for Payer: Preferred Network Access Commercial |
$24,076.92
|
| Rate for Payer: Quartz Beloit One Network |
$12,823.57
|
| Rate for Payer: Quartz Commercial |
$17,010.86
|
| Rate for Payer: Quartz Medicare Advantage |
$15,702.34
|
| Rate for Payer: The Alliance Commercial |
$13,085.28
|
| Rate for Payer: WEA Trust Commercial |
$14,393.81
|
| Rate for Payer: WPS Commercial |
$19,383.83
|
|
|
STEM STD OFFSE TRABEC 18MM 007864-18-00
|
Facility
|
IP
|
$25,164.00
|
|
| Hospital Charge Code |
2967856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,823.57 |
| Max. Negotiated Rate |
$24,076.92 |
| Rate for Payer: Aetna Commercial |
$23,553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,506.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,870.40
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cigna Commercial |
$24,076.92
|
| Rate for Payer: Health EOS Commercial |
$23,291.80
|
| Rate for Payer: HFN Commercial |
$24,076.92
|
| Rate for Payer: Multiplan Commercial |
$20,936.45
|
| Rate for Payer: Preferred Network Access Commercial |
$24,076.92
|
| Rate for Payer: Quartz Beloit One Network |
$12,823.57
|
| Rate for Payer: Quartz Commercial |
$15,702.34
|
| Rate for Payer: WEA Trust Commercial |
$14,393.81
|
| Rate for Payer: WPS Commercial |
$19,383.83
|
|
|
STEM STD OFFSE TRABEC 18MM 007864-18-00
|
Facility
|
OP
|
$25,164.00
|
|
| Hospital Charge Code |
2967856
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,327.76 |
| Max. Negotiated Rate |
$24,076.92 |
| Rate for Payer: Aetna Commercial |
$23,553.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,506.68
|
| Rate for Payer: Aetna Managed Medicare |
$7,327.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,010.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,085.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,561.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,870.40
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cigna Commercial |
$24,076.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,645.45
|
| Rate for Payer: Health EOS Commercial |
$23,291.80
|
| Rate for Payer: HFN Commercial |
$24,076.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,627.92
|
| Rate for Payer: Multiplan Commercial |
$20,936.45
|
| Rate for Payer: NAPHCARE Commercial |
$15,702.34
|
| Rate for Payer: Preferred Network Access Commercial |
$24,076.92
|
| Rate for Payer: Quartz Beloit One Network |
$12,823.57
|
| Rate for Payer: Quartz Commercial |
$17,010.86
|
| Rate for Payer: Quartz Medicare Advantage |
$15,702.34
|
| Rate for Payer: The Alliance Commercial |
$13,085.28
|
| Rate for Payer: WEA Trust Commercial |
$14,393.81
|
| Rate for Payer: WPS Commercial |
$19,383.83
|
|
|
STEM STD OFFSET TRABEC 14MM 00-7864-014-00
|
Facility
|
IP
|
$26,131.00
|
|
| Hospital Charge Code |
2967848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,316.36 |
| Max. Negotiated Rate |
$25,002.14 |
| Rate for Payer: Aetna Commercial |
$24,458.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,371.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,403.41
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$25,002.14
|
| Rate for Payer: Health EOS Commercial |
$24,186.85
|
| Rate for Payer: HFN Commercial |
$25,002.14
|
| Rate for Payer: Multiplan Commercial |
$21,740.99
|
| Rate for Payer: Preferred Network Access Commercial |
$25,002.14
|
| Rate for Payer: Quartz Beloit One Network |
$13,316.36
|
| Rate for Payer: Quartz Commercial |
$16,305.74
|
| Rate for Payer: WEA Trust Commercial |
$14,946.93
|
| Rate for Payer: WPS Commercial |
$20,128.71
|
|
