|
ACETABULAR LINER PINNACLE 36MM 64MM +4 NEUTRAL 1221-36-464
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$55.62 |
| Max. Negotiated Rate |
$182.75 |
| Rate for Payer: Aetna Commercial |
$178.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.83
|
| Rate for Payer: Aetna Managed Medicare |
$55.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.28
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$182.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.16
|
| Rate for Payer: Health EOS Commercial |
$176.79
|
| Rate for Payer: HFN Commercial |
$182.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$148.98
|
| Rate for Payer: Multiplan Commercial |
$158.91
|
| Rate for Payer: NAPHCARE Commercial |
$119.18
|
| Rate for Payer: Preferred Network Access Commercial |
$182.75
|
| Rate for Payer: Quartz Beloit One Network |
$97.33
|
| Rate for Payer: Quartz Commercial |
$129.12
|
| Rate for Payer: Quartz Medicare Advantage |
$119.18
|
| Rate for Payer: The Alliance Commercial |
$99.32
|
| Rate for Payer: WEA Trust Commercial |
$109.25
|
| Rate for Payer: WPS Commercial |
$147.13
|
|
|
ACETABULAR LINER PINNACLE 40MM 56MM +4 10 DEG 1221-40-156
|
Facility
|
OP
|
$5,391.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6198969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,569.86 |
| Max. Negotiated Rate |
$5,158.11 |
| Rate for Payer: Aetna Commercial |
$5,045.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,821.71
|
| Rate for Payer: Aetna Managed Medicare |
$1,569.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,644.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,803.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,691.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,971.52
|
| Rate for Payer: Cash Price |
$1,617.30
|
| Rate for Payer: Cigna Commercial |
$5,158.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,137.56
|
| Rate for Payer: Health EOS Commercial |
$4,989.91
|
| Rate for Payer: HFN Commercial |
$5,158.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,204.98
|
| Rate for Payer: Multiplan Commercial |
$4,485.31
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,158.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,747.25
|
| Rate for Payer: Quartz Commercial |
$3,644.32
|
| Rate for Payer: Quartz Medicare Advantage |
$3,363.98
|
| Rate for Payer: The Alliance Commercial |
$2,803.32
|
| Rate for Payer: WEA Trust Commercial |
$3,083.65
|
| Rate for Payer: WPS Commercial |
$4,152.69
|
|
|
ACETABULAR LINER PINNACLE 40MM 56MM +4 10 DEG 1221-40-156
|
Facility
|
IP
|
$5,391.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6198969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,747.25 |
| Max. Negotiated Rate |
$5,158.11 |
| Rate for Payer: Aetna Commercial |
$5,045.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,821.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,971.52
|
| Rate for Payer: Cash Price |
$1,617.30
|
| Rate for Payer: Cigna Commercial |
$5,158.11
|
| Rate for Payer: Health EOS Commercial |
$4,989.91
|
| Rate for Payer: HFN Commercial |
$5,158.11
|
| Rate for Payer: Multiplan Commercial |
$4,485.31
|
| Rate for Payer: Preferred Network Access Commercial |
$5,158.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,747.25
|
| Rate for Payer: Quartz Commercial |
$3,363.98
|
| Rate for Payer: WEA Trust Commercial |
$3,083.65
|
| Rate for Payer: WPS Commercial |
$4,152.69
|
|
|
ACETABULAR SHELL G7 OSSEO 3HOLE 48MM C 010000661
|
Facility
|
OP
|
$5,255.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,530.26 |
| Max. Negotiated Rate |
$5,027.98 |
| Rate for Payer: Aetna Commercial |
$4,918.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,700.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,530.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,552.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,732.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,623.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,896.56
|
| Rate for Payer: Cash Price |
$1,576.50
|
| Rate for Payer: Cigna Commercial |
$5,027.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,058.41
|
| Rate for Payer: Health EOS Commercial |
$4,864.03
|
| Rate for Payer: HFN Commercial |
$5,027.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,098.90
|
| Rate for Payer: Multiplan Commercial |
$4,372.16
|
| Rate for Payer: NAPHCARE Commercial |
$3,279.12
|
| Rate for Payer: Preferred Network Access Commercial |
$5,027.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,677.95
|
| Rate for Payer: Quartz Commercial |
$3,552.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3,279.12
|
| Rate for Payer: The Alliance Commercial |
$2,732.60
|
| Rate for Payer: WEA Trust Commercial |
$3,005.86
|
| Rate for Payer: WPS Commercial |
$4,047.93
|
|
|
ACETABULAR SHELL G7 OSSEO 3HOLE 48MM C 010000661
|
Facility
|
IP
|
$5,255.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,677.95 |
| Max. Negotiated Rate |
$5,027.98 |
| Rate for Payer: Aetna Commercial |
$4,918.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,700.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,896.56
|
| Rate for Payer: Cash Price |
$1,576.50
|
| Rate for Payer: Cigna Commercial |
$5,027.98
|
| Rate for Payer: Health EOS Commercial |
$4,864.03
|
| Rate for Payer: HFN Commercial |
$5,027.98
|
| Rate for Payer: Multiplan Commercial |
$4,372.16
|
| Rate for Payer: Preferred Network Access Commercial |
$5,027.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,677.95
|
| Rate for Payer: Quartz Commercial |
$3,279.12
|
| Rate for Payer: WEA Trust Commercial |
$3,005.86
|
| Rate for Payer: WPS Commercial |
$4,047.93
|
|
|
ACETABULAR SHELL G7 OSSEO 3HOLE 50MM D 110010243
|
Facility
|
IP
|
$15,695.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,998.17 |
| Max. Negotiated Rate |
$15,016.98 |
| Rate for Payer: Aetna Commercial |
$14,690.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,037.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,651.08
|
| Rate for Payer: Cash Price |
$4,708.50
|
| Rate for Payer: Cigna Commercial |
$15,016.98
|
| Rate for Payer: Health EOS Commercial |
$14,527.29
|
| Rate for Payer: HFN Commercial |
$15,016.98
|
| Rate for Payer: Multiplan Commercial |
$13,058.24
|
| Rate for Payer: Preferred Network Access Commercial |
$15,016.98
|
| Rate for Payer: Quartz Beloit One Network |
$7,998.17
|
| Rate for Payer: Quartz Commercial |
$9,793.68
|
| Rate for Payer: WEA Trust Commercial |
$8,977.54
|
| Rate for Payer: WPS Commercial |
$12,089.86
|
|
|
ACETABULAR SHELL G7 OSSEO 3HOLE 50MM D 110010243
|
Facility
|
OP
|
$15,695.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,570.38 |
| Max. Negotiated Rate |
$15,016.98 |
| Rate for Payer: Aetna Commercial |
$14,690.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,037.61
|
| Rate for Payer: Aetna Managed Medicare |
$4,570.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,609.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,161.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,834.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,651.08
|
| Rate for Payer: Cash Price |
$4,708.50
|
| Rate for Payer: Cigna Commercial |
$15,016.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,134.49
|
| Rate for Payer: Health EOS Commercial |
$14,527.29
|
| Rate for Payer: HFN Commercial |
$15,016.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,242.10
|
| Rate for Payer: Multiplan Commercial |
$13,058.24
|
| Rate for Payer: NAPHCARE Commercial |
$9,793.68
|
| Rate for Payer: Preferred Network Access Commercial |
$15,016.98
|
| Rate for Payer: Quartz Beloit One Network |
$7,998.17
|
| Rate for Payer: Quartz Commercial |
$10,609.82
|
| Rate for Payer: Quartz Medicare Advantage |
$9,793.68
|
| Rate for Payer: The Alliance Commercial |
$8,161.40
|
| Rate for Payer: WEA Trust Commercial |
$8,977.54
|
| Rate for Payer: WPS Commercial |
$12,089.86
|
|
|
ACETABULAR SHELL G7 OSSEO 3HOLE 52MM E 110010244
|
Facility
|
OP
|
$15,695.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,570.38 |
| Max. Negotiated Rate |
$15,016.98 |
| Rate for Payer: Aetna Commercial |
$14,690.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,037.61
|
| Rate for Payer: Aetna Managed Medicare |
$4,570.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,609.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,161.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,834.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,651.08
|
| Rate for Payer: Cash Price |
$4,708.50
|
| Rate for Payer: Cigna Commercial |
$15,016.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,134.49
|
| Rate for Payer: Health EOS Commercial |
$14,527.29
|
| Rate for Payer: HFN Commercial |
$15,016.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,242.10
|
| Rate for Payer: Multiplan Commercial |
$13,058.24
|
| Rate for Payer: NAPHCARE Commercial |
$9,793.68
|
| Rate for Payer: Preferred Network Access Commercial |
$15,016.98
|
| Rate for Payer: Quartz Beloit One Network |
$7,998.17
|
| Rate for Payer: Quartz Commercial |
$10,609.82
|
| Rate for Payer: Quartz Medicare Advantage |
$9,793.68
|
| Rate for Payer: The Alliance Commercial |
$8,161.40
|
| Rate for Payer: WEA Trust Commercial |
$8,977.54
|
| Rate for Payer: WPS Commercial |
$12,089.86
|
|
|
ACETABULAR SHELL G7 OSSEO 3HOLE 52MM E 110010244
|
Facility
|
IP
|
$15,695.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,998.17 |
| Max. Negotiated Rate |
$15,016.98 |
| Rate for Payer: Aetna Commercial |
$14,690.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,037.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,651.08
|
| Rate for Payer: Cash Price |
$4,708.50
|
| Rate for Payer: Cigna Commercial |
$15,016.98
|
| Rate for Payer: Health EOS Commercial |
$14,527.29
|
| Rate for Payer: HFN Commercial |
$15,016.98
|
| Rate for Payer: Multiplan Commercial |
$13,058.24
|
| Rate for Payer: Preferred Network Access Commercial |
$15,016.98
|
| Rate for Payer: Quartz Beloit One Network |
$7,998.17
|
| Rate for Payer: Quartz Commercial |
$9,793.68
|
| Rate for Payer: WEA Trust Commercial |
$8,977.54
|
| Rate for Payer: WPS Commercial |
$12,089.86
|
|
|
ACETABULAR SHELL G7 OSSEO TI 4HL 110010245
|
Facility
|
IP
|
$15,695.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,998.17 |
| Max. Negotiated Rate |
$15,016.98 |
| Rate for Payer: Aetna Commercial |
$14,690.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,037.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,651.08
|
| Rate for Payer: Cash Price |
$4,708.50
|
| Rate for Payer: Cigna Commercial |
$15,016.98
|
| Rate for Payer: Health EOS Commercial |
$14,527.29
|
| Rate for Payer: HFN Commercial |
$15,016.98
|
| Rate for Payer: Multiplan Commercial |
$13,058.24
|
| Rate for Payer: Preferred Network Access Commercial |
$15,016.98
|
| Rate for Payer: Quartz Beloit One Network |
$7,998.17
|
| Rate for Payer: Quartz Commercial |
$9,793.68
|
| Rate for Payer: WEA Trust Commercial |
$8,977.54
|
| Rate for Payer: WPS Commercial |
$12,089.86
|
|
|
ACETABULAR SHELL G7 OSSEO TI 4HL 110010245
|
Facility
|
OP
|
$15,695.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,570.38 |
| Max. Negotiated Rate |
$15,016.98 |
| Rate for Payer: Aetna Commercial |
$14,690.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,037.61
|
| Rate for Payer: Aetna Managed Medicare |
$4,570.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,609.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,161.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,834.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,651.08
|
| Rate for Payer: Cash Price |
$4,708.50
|
| Rate for Payer: Cigna Commercial |
$15,016.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,134.49
|
| Rate for Payer: Health EOS Commercial |
$14,527.29
|
| Rate for Payer: HFN Commercial |
$15,016.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,242.10
|
| Rate for Payer: Multiplan Commercial |
$13,058.24
|
| Rate for Payer: NAPHCARE Commercial |
$9,793.68
|
| Rate for Payer: Preferred Network Access Commercial |
$15,016.98
|
| Rate for Payer: Quartz Beloit One Network |
$7,998.17
|
| Rate for Payer: Quartz Commercial |
$10,609.82
|
| Rate for Payer: Quartz Medicare Advantage |
$9,793.68
|
| Rate for Payer: The Alliance Commercial |
$8,161.40
|
| Rate for Payer: WEA Trust Commercial |
$8,977.54
|
| Rate for Payer: WPS Commercial |
$12,089.86
|
|
|
ACETABULAR SHELL G7 PPS LTD 52E 010000663
|
Facility
|
OP
|
$4,259.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6220190
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,240.22 |
| Max. Negotiated Rate |
$4,075.01 |
| Rate for Payer: Aetna Commercial |
$3,986.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,809.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,240.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,879.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,214.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,126.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,347.56
|
| Rate for Payer: Cash Price |
$1,277.70
|
| Rate for Payer: Cigna Commercial |
$4,075.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,478.74
|
| Rate for Payer: Health EOS Commercial |
$3,942.13
|
| Rate for Payer: HFN Commercial |
$4,075.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,322.02
|
| Rate for Payer: Multiplan Commercial |
$3,543.49
|
| Rate for Payer: NAPHCARE Commercial |
$2,657.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,075.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,170.39
|
| Rate for Payer: Quartz Commercial |
$2,879.08
|
| Rate for Payer: Quartz Medicare Advantage |
$2,657.62
|
| Rate for Payer: The Alliance Commercial |
$2,214.68
|
| Rate for Payer: WEA Trust Commercial |
$2,436.15
|
| Rate for Payer: WPS Commercial |
$3,280.71
|
|
|
ACETABULAR SHELL G7 PPS LTD 52E 010000663
|
Facility
|
IP
|
$4,259.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6220190
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,170.39 |
| Max. Negotiated Rate |
$4,075.01 |
| Rate for Payer: Aetna Commercial |
$3,986.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,809.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,347.56
|
| Rate for Payer: Cash Price |
$1,277.70
|
| Rate for Payer: Cigna Commercial |
$4,075.01
|
| Rate for Payer: Health EOS Commercial |
$3,942.13
|
| Rate for Payer: HFN Commercial |
$4,075.01
|
| Rate for Payer: Multiplan Commercial |
$3,543.49
|
| Rate for Payer: Preferred Network Access Commercial |
$4,075.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,170.39
|
| Rate for Payer: Quartz Commercial |
$2,657.62
|
| Rate for Payer: WEA Trust Commercial |
$2,436.15
|
| Rate for Payer: WPS Commercial |
$3,280.71
|
|
|
ACETABULAR SHELL PINNACLE 22MM 48MM 1217-22-048
|
Facility
|
IP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5497001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,186.36 |
| Max. Negotiated Rate |
$7,860.11 |
| Rate for Payer: Aetna Commercial |
$7,689.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,347.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,528.11
|
| Rate for Payer: Cash Price |
$2,464.50
|
| Rate for Payer: Cigna Commercial |
$7,860.11
|
| Rate for Payer: Health EOS Commercial |
$7,603.80
|
| Rate for Payer: HFN Commercial |
$7,860.11
|
| Rate for Payer: Multiplan Commercial |
$6,834.88
|
| Rate for Payer: Preferred Network Access Commercial |
$7,860.11
|
| Rate for Payer: Quartz Beloit One Network |
$4,186.36
|
| Rate for Payer: Quartz Commercial |
$5,126.16
|
| Rate for Payer: WEA Trust Commercial |
$4,698.98
|
| Rate for Payer: WPS Commercial |
$6,328.01
|
|
|
ACETABULAR SHELL PINNACLE 22MM 48MM 1217-22-048
|
Facility
|
OP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5497001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.21 |
| Max. Negotiated Rate |
$7,860.11 |
| Rate for Payer: Aetna Commercial |
$7,689.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,347.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,392.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,553.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,271.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,100.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,528.11
|
| Rate for Payer: Cash Price |
$2,464.50
|
| Rate for Payer: Cigna Commercial |
$7,860.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,781.13
|
| Rate for Payer: Health EOS Commercial |
$7,603.80
|
| Rate for Payer: HFN Commercial |
$7,860.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,407.70
|
| Rate for Payer: Multiplan Commercial |
$6,834.88
|
| Rate for Payer: NAPHCARE Commercial |
$5,126.16
|
| Rate for Payer: Preferred Network Access Commercial |
$7,860.11
|
| Rate for Payer: Quartz Beloit One Network |
$4,186.36
|
| Rate for Payer: Quartz Commercial |
$5,553.34
|
| Rate for Payer: Quartz Medicare Advantage |
$5,126.16
|
| Rate for Payer: The Alliance Commercial |
$4,271.80
|
| Rate for Payer: WEA Trust Commercial |
$4,698.98
|
| Rate for Payer: WPS Commercial |
$6,328.01
|
|
|
ACETABULAR SHELL PINNACLE 22MM 50MM 1217-22-050
|
Facility
|
IP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459304
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.89 |
| Max. Negotiated Rate |
$8,161.50 |
| Rate for Payer: Aetna Commercial |
$7,984.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,629.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,701.74
|
| Rate for Payer: Cash Price |
$2,559.00
|
| Rate for Payer: Cigna Commercial |
$8,161.50
|
| Rate for Payer: Health EOS Commercial |
$7,895.37
|
| Rate for Payer: HFN Commercial |
$8,161.50
|
| Rate for Payer: Multiplan Commercial |
$7,096.96
|
| Rate for Payer: Preferred Network Access Commercial |
$8,161.50
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.89
|
| Rate for Payer: Quartz Commercial |
$5,322.72
|
| Rate for Payer: WEA Trust Commercial |
$4,879.16
|
| Rate for Payer: WPS Commercial |
$6,570.66
|
|
|
ACETABULAR SHELL PINNACLE 22MM 50MM 1217-22-050
|
Facility
|
OP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459304
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,483.94 |
| Max. Negotiated Rate |
$8,161.50 |
| Rate for Payer: Aetna Commercial |
$7,984.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,629.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,483.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,766.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,435.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,258.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,701.74
|
| Rate for Payer: Cash Price |
$2,559.00
|
| Rate for Payer: Cigna Commercial |
$8,161.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,964.46
|
| Rate for Payer: Health EOS Commercial |
$7,895.37
|
| Rate for Payer: HFN Commercial |
$8,161.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,653.40
|
| Rate for Payer: Multiplan Commercial |
$7,096.96
|
| Rate for Payer: NAPHCARE Commercial |
$5,322.72
|
| Rate for Payer: Preferred Network Access Commercial |
$8,161.50
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.89
|
| Rate for Payer: Quartz Commercial |
$5,766.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,322.72
|
| Rate for Payer: The Alliance Commercial |
$4,435.60
|
| Rate for Payer: WEA Trust Commercial |
$4,879.16
|
| Rate for Payer: WPS Commercial |
$6,570.66
|
|
|
ACETABULAR SHELL PINNACLE 22MM 52MM 1217-22-052
|
Facility
|
IP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.89 |
| Max. Negotiated Rate |
$8,161.50 |
| Rate for Payer: Aetna Commercial |
$7,984.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,629.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,701.74
|
| Rate for Payer: Cash Price |
$2,559.00
|
| Rate for Payer: Cigna Commercial |
$8,161.50
|
| Rate for Payer: Health EOS Commercial |
$7,895.37
|
| Rate for Payer: HFN Commercial |
$8,161.50
|
| Rate for Payer: Multiplan Commercial |
$7,096.96
|
| Rate for Payer: Preferred Network Access Commercial |
$8,161.50
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.89
|
| Rate for Payer: Quartz Commercial |
$5,322.72
|
| Rate for Payer: WEA Trust Commercial |
$4,879.16
|
| Rate for Payer: WPS Commercial |
$6,570.66
|
|
|
ACETABULAR SHELL PINNACLE 22MM 52MM 1217-22-052
|
Facility
|
OP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,483.94 |
| Max. Negotiated Rate |
$8,161.50 |
| Rate for Payer: Aetna Commercial |
$7,984.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,629.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,483.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,766.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,435.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,258.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,701.74
|
| Rate for Payer: Cash Price |
$2,559.00
|
| Rate for Payer: Cigna Commercial |
$8,161.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,964.46
|
| Rate for Payer: Health EOS Commercial |
$7,895.37
|
| Rate for Payer: HFN Commercial |
$8,161.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,653.40
|
| Rate for Payer: Multiplan Commercial |
$7,096.96
|
| Rate for Payer: NAPHCARE Commercial |
$5,322.72
|
| Rate for Payer: Preferred Network Access Commercial |
$8,161.50
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.89
|
| Rate for Payer: Quartz Commercial |
$5,766.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,322.72
|
| Rate for Payer: The Alliance Commercial |
$4,435.60
|
| Rate for Payer: WEA Trust Commercial |
$4,879.16
|
| Rate for Payer: WPS Commercial |
$6,570.66
|
|
|
ACETABULAR SHELL PINNACLE 22MM 54MM 1217-22-054
|
Facility
|
OP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,483.94 |
| Max. Negotiated Rate |
$8,161.50 |
| Rate for Payer: Aetna Commercial |
$7,984.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,629.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,483.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,766.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,435.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,258.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,701.74
|
| Rate for Payer: Cash Price |
$2,559.00
|
| Rate for Payer: Cigna Commercial |
$8,161.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,964.46
|
| Rate for Payer: Health EOS Commercial |
$7,895.37
|
| Rate for Payer: HFN Commercial |
$8,161.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,653.40
|
| Rate for Payer: Multiplan Commercial |
$7,096.96
|
| Rate for Payer: NAPHCARE Commercial |
$5,322.72
|
| Rate for Payer: Preferred Network Access Commercial |
$8,161.50
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.89
|
| Rate for Payer: Quartz Commercial |
$5,766.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,322.72
|
| Rate for Payer: The Alliance Commercial |
$4,435.60
|
| Rate for Payer: WEA Trust Commercial |
$4,879.16
|
| Rate for Payer: WPS Commercial |
$6,570.66
|
|
|
ACETABULAR SHELL PINNACLE 22MM 54MM 1217-22-054
|
Facility
|
IP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.89 |
| Max. Negotiated Rate |
$8,161.50 |
| Rate for Payer: Aetna Commercial |
$7,984.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,629.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,701.74
|
| Rate for Payer: Cash Price |
$2,559.00
|
| Rate for Payer: Cigna Commercial |
$8,161.50
|
| Rate for Payer: Health EOS Commercial |
$7,895.37
|
| Rate for Payer: HFN Commercial |
$8,161.50
|
| Rate for Payer: Multiplan Commercial |
$7,096.96
|
| Rate for Payer: Preferred Network Access Commercial |
$8,161.50
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.89
|
| Rate for Payer: Quartz Commercial |
$5,322.72
|
| Rate for Payer: WEA Trust Commercial |
$4,879.16
|
| Rate for Payer: WPS Commercial |
$6,570.66
|
|
|
ACETABULAR SHELL PINNACLE 22MM 56MM 1217-22-056
|
Facility
|
OP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,483.94 |
| Max. Negotiated Rate |
$8,161.50 |
| Rate for Payer: Aetna Commercial |
$7,984.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,629.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,483.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,766.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,435.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,258.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,701.74
|
| Rate for Payer: Cash Price |
$2,559.00
|
| Rate for Payer: Cigna Commercial |
$8,161.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,964.46
|
| Rate for Payer: Health EOS Commercial |
$7,895.37
|
| Rate for Payer: HFN Commercial |
$8,161.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,653.40
|
| Rate for Payer: Multiplan Commercial |
$7,096.96
|
| Rate for Payer: NAPHCARE Commercial |
$5,322.72
|
| Rate for Payer: Preferred Network Access Commercial |
$8,161.50
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.89
|
| Rate for Payer: Quartz Commercial |
$5,766.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,322.72
|
| Rate for Payer: The Alliance Commercial |
$4,435.60
|
| Rate for Payer: WEA Trust Commercial |
$4,879.16
|
| Rate for Payer: WPS Commercial |
$6,570.66
|
|
|
ACETABULAR SHELL PINNACLE 22MM 56MM 1217-22-056
|
Facility
|
IP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.89 |
| Max. Negotiated Rate |
$8,161.50 |
| Rate for Payer: Aetna Commercial |
$7,984.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,629.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,701.74
|
| Rate for Payer: Cash Price |
$2,559.00
|
| Rate for Payer: Cigna Commercial |
$8,161.50
|
| Rate for Payer: Health EOS Commercial |
$7,895.37
|
| Rate for Payer: HFN Commercial |
$8,161.50
|
| Rate for Payer: Multiplan Commercial |
$7,096.96
|
| Rate for Payer: Preferred Network Access Commercial |
$8,161.50
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.89
|
| Rate for Payer: Quartz Commercial |
$5,322.72
|
| Rate for Payer: WEA Trust Commercial |
$4,879.16
|
| Rate for Payer: WPS Commercial |
$6,570.66
|
|
|
ACETABULAR SHELL PINNACLE 22MM 58MM 1217-22-058
|
Facility
|
OP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.21 |
| Max. Negotiated Rate |
$7,860.11 |
| Rate for Payer: Aetna Commercial |
$7,689.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,347.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,392.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,553.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,271.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,100.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,528.11
|
| Rate for Payer: Cash Price |
$2,464.50
|
| Rate for Payer: Cigna Commercial |
$7,860.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,781.13
|
| Rate for Payer: Health EOS Commercial |
$7,603.80
|
| Rate for Payer: HFN Commercial |
$7,860.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,407.70
|
| Rate for Payer: Multiplan Commercial |
$6,834.88
|
| Rate for Payer: NAPHCARE Commercial |
$5,126.16
|
| Rate for Payer: Preferred Network Access Commercial |
$7,860.11
|
| Rate for Payer: Quartz Beloit One Network |
$4,186.36
|
| Rate for Payer: Quartz Commercial |
$5,553.34
|
| Rate for Payer: Quartz Medicare Advantage |
$5,126.16
|
| Rate for Payer: The Alliance Commercial |
$4,271.80
|
| Rate for Payer: WEA Trust Commercial |
$4,698.98
|
| Rate for Payer: WPS Commercial |
$6,328.01
|
|
|
ACETABULAR SHELL PINNACLE 22MM 58MM 1217-22-058
|
Facility
|
IP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,186.36 |
| Max. Negotiated Rate |
$7,860.11 |
| Rate for Payer: Aetna Commercial |
$7,689.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,347.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,528.11
|
| Rate for Payer: Cash Price |
$2,464.50
|
| Rate for Payer: Cigna Commercial |
$7,860.11
|
| Rate for Payer: Health EOS Commercial |
$7,603.80
|
| Rate for Payer: HFN Commercial |
$7,860.11
|
| Rate for Payer: Multiplan Commercial |
$6,834.88
|
| Rate for Payer: Preferred Network Access Commercial |
$7,860.11
|
| Rate for Payer: Quartz Beloit One Network |
$4,186.36
|
| Rate for Payer: Quartz Commercial |
$5,126.16
|
| Rate for Payer: WEA Trust Commercial |
$4,698.98
|
| Rate for Payer: WPS Commercial |
$6,328.01
|
|
