|
ACETABULAR SHELL PINNACLE 22MM 60MM 1217-22-060
|
Facility
|
OP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5497007
|
|
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 60MM 1217-22-060
|
Facility
|
IP
|
$8,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5497007
|
|
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 62MM 1217-22-062
|
Facility
|
OP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5547325
|
|
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 62MM 1217-22-062
|
Facility
|
IP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5547325
|
|
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 64MM 1217-22-064
|
Facility
|
OP
|
$6,064.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181296
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,765.84 |
| Max. Negotiated Rate |
$5,802.04 |
| Rate for Payer: Aetna Commercial |
$5,675.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,423.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,765.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,099.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,153.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,027.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,342.48
|
| Rate for Payer: Cash Price |
$1,819.20
|
| Rate for Payer: Cigna Commercial |
$5,802.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,529.25
|
| Rate for Payer: Health EOS Commercial |
$5,612.84
|
| Rate for Payer: HFN Commercial |
$5,802.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,729.92
|
| Rate for Payer: Multiplan Commercial |
$5,045.25
|
| Rate for Payer: NAPHCARE Commercial |
$3,783.94
|
| Rate for Payer: Preferred Network Access Commercial |
$5,802.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,090.21
|
| Rate for Payer: Quartz Commercial |
$4,099.26
|
| Rate for Payer: Quartz Medicare Advantage |
$3,783.94
|
| Rate for Payer: The Alliance Commercial |
$3,153.28
|
| Rate for Payer: WEA Trust Commercial |
$3,468.61
|
| Rate for Payer: WPS Commercial |
$4,671.10
|
|
|
ACETABULAR SHELL PINNACLE 22MM 64MM 1217-22-064
|
Facility
|
IP
|
$6,064.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181296
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,090.21 |
| Max. Negotiated Rate |
$5,802.04 |
| Rate for Payer: Aetna Commercial |
$5,675.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,423.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,342.48
|
| Rate for Payer: Cash Price |
$1,819.20
|
| Rate for Payer: Cigna Commercial |
$5,802.04
|
| Rate for Payer: Health EOS Commercial |
$5,612.84
|
| Rate for Payer: HFN Commercial |
$5,802.04
|
| Rate for Payer: Multiplan Commercial |
$5,045.25
|
| Rate for Payer: Preferred Network Access Commercial |
$5,802.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,090.21
|
| Rate for Payer: Quartz Commercial |
$3,783.94
|
| Rate for Payer: WEA Trust Commercial |
$3,468.61
|
| Rate for Payer: WPS Commercial |
$4,671.10
|
|
|
ACETABULAR SHELL PINNACLE 32MM 48MM 1217-32-048
|
Facility
|
OP
|
$5,466.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831739
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,591.70 |
| Max. Negotiated Rate |
$5,229.87 |
| Rate for Payer: Aetna Commercial |
$5,116.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,888.79
|
| Rate for Payer: Aetna Managed Medicare |
$1,591.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,695.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,842.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,728.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,012.86
|
| Rate for Payer: Cash Price |
$1,639.80
|
| Rate for Payer: Cigna Commercial |
$5,229.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,181.21
|
| Rate for Payer: Health EOS Commercial |
$5,059.33
|
| Rate for Payer: HFN Commercial |
$5,229.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,263.48
|
| Rate for Payer: Multiplan Commercial |
$4,547.71
|
| Rate for Payer: NAPHCARE Commercial |
$3,410.78
|
| Rate for Payer: Preferred Network Access Commercial |
$5,229.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,785.47
|
| Rate for Payer: Quartz Commercial |
$3,695.02
|
| Rate for Payer: Quartz Medicare Advantage |
$3,410.78
|
| Rate for Payer: The Alliance Commercial |
$2,842.32
|
| Rate for Payer: WEA Trust Commercial |
$3,126.55
|
| Rate for Payer: WPS Commercial |
$4,210.46
|
|
|
ACETABULAR SHELL PINNACLE 32MM 48MM 1217-32-048
|
Facility
|
IP
|
$5,466.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831739
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,785.47 |
| Max. Negotiated Rate |
$5,229.87 |
| Rate for Payer: Aetna Commercial |
$5,116.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,888.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,012.86
|
| Rate for Payer: Cash Price |
$1,639.80
|
| Rate for Payer: Cigna Commercial |
$5,229.87
|
| Rate for Payer: Health EOS Commercial |
$5,059.33
|
| Rate for Payer: HFN Commercial |
$5,229.87
|
| Rate for Payer: Multiplan Commercial |
$4,547.71
|
| Rate for Payer: Preferred Network Access Commercial |
$5,229.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,785.47
|
| Rate for Payer: Quartz Commercial |
$3,410.78
|
| Rate for Payer: WEA Trust Commercial |
$3,126.55
|
| Rate for Payer: WPS Commercial |
$4,210.46
|
|
|
ACETABULAR SHELL PINNACLE 32MM 52MM 1217-32-052
|
Facility
|
OP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459454
|
|
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 32MM 52MM 1217-32-052
|
Facility
|
IP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459454
|
|
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 32MM 56MM 1217-32-056
|
Facility
|
IP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459757
|
|
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 32MM 56MM 1217-32-056
|
Facility
|
OP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459757
|
|
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 32MM 58MM 1217-32-058
|
Facility
|
OP
|
$5,850.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563222
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,703.52 |
| Max. Negotiated Rate |
$5,597.28 |
| Rate for Payer: Aetna Commercial |
$5,475.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,232.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,703.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,954.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,042.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,920.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,224.52
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cigna Commercial |
$5,597.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,404.70
|
| Rate for Payer: Health EOS Commercial |
$5,414.76
|
| Rate for Payer: HFN Commercial |
$5,597.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,563.00
|
| Rate for Payer: Multiplan Commercial |
$4,867.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,597.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,981.16
|
| Rate for Payer: Quartz Commercial |
$3,954.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,650.40
|
| Rate for Payer: The Alliance Commercial |
$3,042.00
|
| Rate for Payer: WEA Trust Commercial |
$3,346.20
|
| Rate for Payer: WPS Commercial |
$4,506.26
|
|
|
ACETABULAR SHELL PINNACLE 32MM 58MM 1217-32-058
|
Facility
|
IP
|
$5,850.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563222
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,981.16 |
| Max. Negotiated Rate |
$5,597.28 |
| Rate for Payer: Aetna Commercial |
$5,475.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,232.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,224.52
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cigna Commercial |
$5,597.28
|
| Rate for Payer: Health EOS Commercial |
$5,414.76
|
| Rate for Payer: HFN Commercial |
$5,597.28
|
| Rate for Payer: Multiplan Commercial |
$4,867.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,597.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,981.16
|
| Rate for Payer: Quartz Commercial |
$3,650.40
|
| Rate for Payer: WEA Trust Commercial |
$3,346.20
|
| Rate for Payer: WPS Commercial |
$4,506.26
|
|
|
ACETABULAR SHELL PINNACLE 32MM 60MM 1217-32-060
|
Facility
|
IP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496874
|
|
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 32MM 60MM 1217-32-060
|
Facility
|
OP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496874
|
|
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 32MM 62MM 1217-32-062
|
Facility
|
OP
|
$5,054.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6202962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.72 |
| Max. Negotiated Rate |
$4,835.67 |
| Rate for Payer: Aetna Commercial |
$4,730.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,520.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,471.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,416.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,628.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,522.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.76
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cigna Commercial |
$4,835.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,941.43
|
| Rate for Payer: Health EOS Commercial |
$4,677.98
|
| Rate for Payer: HFN Commercial |
$4,835.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,942.12
|
| Rate for Payer: Multiplan Commercial |
$4,204.93
|
| Rate for Payer: NAPHCARE Commercial |
$3,153.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,835.67
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.52
|
| Rate for Payer: Quartz Commercial |
$3,416.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,153.70
|
| Rate for Payer: The Alliance Commercial |
$2,628.08
|
| Rate for Payer: WEA Trust Commercial |
$2,890.89
|
| Rate for Payer: WPS Commercial |
$3,893.10
|
|
|
ACETABULAR SHELL PINNACLE 32MM 62MM 1217-32-062
|
Facility
|
IP
|
$5,054.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6202962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,575.52 |
| Max. Negotiated Rate |
$4,835.67 |
| Rate for Payer: Aetna Commercial |
$4,730.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,520.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.76
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cigna Commercial |
$4,835.67
|
| Rate for Payer: Health EOS Commercial |
$4,677.98
|
| Rate for Payer: HFN Commercial |
$4,835.67
|
| Rate for Payer: Multiplan Commercial |
$4,204.93
|
| Rate for Payer: Preferred Network Access Commercial |
$4,835.67
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.52
|
| Rate for Payer: Quartz Commercial |
$3,153.70
|
| Rate for Payer: WEA Trust Commercial |
$2,890.89
|
| Rate for Payer: WPS Commercial |
$3,893.10
|
|
|
ACETABULAR SHELL PINNACLE 32MM 64MM 1217-32-064
|
Facility
|
IP
|
$5,054.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6182536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,575.52 |
| Max. Negotiated Rate |
$4,835.67 |
| Rate for Payer: Aetna Commercial |
$4,730.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,520.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.76
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cigna Commercial |
$4,835.67
|
| Rate for Payer: Health EOS Commercial |
$4,677.98
|
| Rate for Payer: HFN Commercial |
$4,835.67
|
| Rate for Payer: Multiplan Commercial |
$4,204.93
|
| Rate for Payer: Preferred Network Access Commercial |
$4,835.67
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.52
|
| Rate for Payer: Quartz Commercial |
$3,153.70
|
| Rate for Payer: WEA Trust Commercial |
$2,890.89
|
| Rate for Payer: WPS Commercial |
$3,893.10
|
|
|
ACETABULAR SHELL PINNACLE 32MM 64MM 1217-32-064
|
Facility
|
OP
|
$5,054.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6182536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.72 |
| Max. Negotiated Rate |
$4,835.67 |
| Rate for Payer: Aetna Commercial |
$4,730.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,520.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,471.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,416.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,628.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,522.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.76
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cigna Commercial |
$4,835.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,941.43
|
| Rate for Payer: Health EOS Commercial |
$4,677.98
|
| Rate for Payer: HFN Commercial |
$4,835.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,942.12
|
| Rate for Payer: Multiplan Commercial |
$4,204.93
|
| Rate for Payer: NAPHCARE Commercial |
$3,153.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,835.67
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.52
|
| Rate for Payer: Quartz Commercial |
$3,416.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,153.70
|
| Rate for Payer: The Alliance Commercial |
$2,628.08
|
| Rate for Payer: WEA Trust Commercial |
$2,890.89
|
| Rate for Payer: WPS Commercial |
$3,893.10
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 48MM 1217-30-048
|
Facility
|
OP
|
$22,068.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603542
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,426.20 |
| Max. Negotiated Rate |
$21,114.66 |
| Rate for Payer: Aetna Commercial |
$20,655.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,737.62
|
| Rate for Payer: Aetna Managed Medicare |
$6,426.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,917.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,475.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,016.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,163.88
|
| Rate for Payer: Cash Price |
$6,620.40
|
| Rate for Payer: Cigna Commercial |
$21,114.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,843.58
|
| Rate for Payer: Health EOS Commercial |
$20,426.14
|
| Rate for Payer: HFN Commercial |
$21,114.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,213.04
|
| Rate for Payer: Multiplan Commercial |
$18,360.58
|
| Rate for Payer: NAPHCARE Commercial |
$13,770.43
|
| Rate for Payer: Preferred Network Access Commercial |
$21,114.66
|
| Rate for Payer: Quartz Beloit One Network |
$11,245.85
|
| Rate for Payer: Quartz Commercial |
$14,917.97
|
| Rate for Payer: Quartz Medicare Advantage |
$13,770.43
|
| Rate for Payer: The Alliance Commercial |
$11,475.36
|
| Rate for Payer: WEA Trust Commercial |
$12,622.90
|
| Rate for Payer: WPS Commercial |
$16,998.98
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 48MM 1217-30-048
|
Facility
|
IP
|
$22,068.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603542
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,245.85 |
| Max. Negotiated Rate |
$21,114.66 |
| Rate for Payer: Aetna Commercial |
$20,655.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,737.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,163.88
|
| Rate for Payer: Cash Price |
$6,620.40
|
| Rate for Payer: Cigna Commercial |
$21,114.66
|
| Rate for Payer: Health EOS Commercial |
$20,426.14
|
| Rate for Payer: HFN Commercial |
$21,114.66
|
| Rate for Payer: Multiplan Commercial |
$18,360.58
|
| Rate for Payer: Preferred Network Access Commercial |
$21,114.66
|
| Rate for Payer: Quartz Beloit One Network |
$11,245.85
|
| Rate for Payer: Quartz Commercial |
$13,770.43
|
| Rate for Payer: WEA Trust Commercial |
$12,622.90
|
| Rate for Payer: WPS Commercial |
$16,998.98
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 56MM 1217-30-056
|
Facility
|
IP
|
$19,618.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,997.33 |
| Max. Negotiated Rate |
$18,770.50 |
| Rate for Payer: Aetna Commercial |
$18,362.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,546.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,813.44
|
| Rate for Payer: Cash Price |
$5,885.40
|
| Rate for Payer: Cigna Commercial |
$18,770.50
|
| Rate for Payer: Health EOS Commercial |
$18,158.42
|
| Rate for Payer: HFN Commercial |
$18,770.50
|
| Rate for Payer: Multiplan Commercial |
$16,322.18
|
| Rate for Payer: Preferred Network Access Commercial |
$18,770.50
|
| Rate for Payer: Quartz Beloit One Network |
$9,997.33
|
| Rate for Payer: Quartz Commercial |
$12,241.63
|
| Rate for Payer: WEA Trust Commercial |
$11,221.50
|
| Rate for Payer: WPS Commercial |
$15,111.75
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 56MM 1217-30-056
|
Facility
|
OP
|
$19,618.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,712.76 |
| Max. Negotiated Rate |
$18,770.50 |
| Rate for Payer: Aetna Commercial |
$18,362.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,546.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,712.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,261.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,201.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,793.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,813.44
|
| Rate for Payer: Cash Price |
$5,885.40
|
| Rate for Payer: Cigna Commercial |
$18,770.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,417.68
|
| Rate for Payer: Health EOS Commercial |
$18,158.42
|
| Rate for Payer: HFN Commercial |
$18,770.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,302.04
|
| Rate for Payer: Multiplan Commercial |
$16,322.18
|
| Rate for Payer: NAPHCARE Commercial |
$12,241.63
|
| Rate for Payer: Preferred Network Access Commercial |
$18,770.50
|
| Rate for Payer: Quartz Beloit One Network |
$9,997.33
|
| Rate for Payer: Quartz Commercial |
$13,261.77
|
| Rate for Payer: Quartz Medicare Advantage |
$12,241.63
|
| Rate for Payer: The Alliance Commercial |
$10,201.36
|
| Rate for Payer: WEA Trust Commercial |
$11,221.50
|
| Rate for Payer: WPS Commercial |
$15,111.75
|
|
|
ACETABULAR SHELL PINNACLE GRIPTION 58MM 1217-30-058
|
Facility
|
OP
|
$21,219.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5895655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,178.97 |
| Max. Negotiated Rate |
$20,302.34 |
| Rate for Payer: Aetna Commercial |
$19,860.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,978.27
|
| Rate for Payer: Aetna Managed Medicare |
$6,178.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,344.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,033.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,592.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,695.91
|
| Rate for Payer: Cash Price |
$6,365.70
|
| Rate for Payer: Cigna Commercial |
$20,302.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.46
|
| Rate for Payer: Health EOS Commercial |
$19,640.31
|
| Rate for Payer: HFN Commercial |
$20,302.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,550.82
|
| Rate for Payer: Multiplan Commercial |
$17,654.21
|
| Rate for Payer: NAPHCARE Commercial |
$13,240.66
|
| Rate for Payer: Preferred Network Access Commercial |
$20,302.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,813.20
|
| Rate for Payer: Quartz Commercial |
$14,344.04
|
| Rate for Payer: Quartz Medicare Advantage |
$13,240.66
|
| Rate for Payer: The Alliance Commercial |
$11,033.88
|
| Rate for Payer: WEA Trust Commercial |
$12,137.27
|
| Rate for Payer: WPS Commercial |
$16,345.00
|
|
