|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 4 8MM CEMENTED 1547-04-002
|
Facility
|
IP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,651.63 |
| Max. Negotiated Rate |
$8,733.67 |
| Rate for Payer: Aetna Commercial |
$8,543.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.35
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,733.67
|
| Rate for Payer: Health EOS Commercial |
$8,448.88
|
| Rate for Payer: HFN Commercial |
$8,733.67
|
| Rate for Payer: Multiplan Commercial |
$7,594.50
|
| Rate for Payer: Preferred Network Access Commercial |
$8,733.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.63
|
| Rate for Payer: Quartz Commercial |
$5,695.87
|
| Rate for Payer: WEA Trust Commercial |
$5,221.22
|
| Rate for Payer: WPS Commercial |
$7,031.30
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 7 4MM CEMENTED 1547-07-001
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,806.02 |
| Max. Negotiated Rate |
$5,934.07 |
| Rate for Payer: Aetna Commercial |
$5,805.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,806.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,192.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,225.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,096.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,418.54
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,934.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,609.56
|
| Rate for Payer: Health EOS Commercial |
$5,740.57
|
| Rate for Payer: HFN Commercial |
$5,934.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,837.56
|
| Rate for Payer: Multiplan Commercial |
$5,160.06
|
| Rate for Payer: NAPHCARE Commercial |
$3,870.05
|
| Rate for Payer: Preferred Network Access Commercial |
$5,934.07
|
| Rate for Payer: Quartz Beloit One Network |
$3,160.54
|
| Rate for Payer: Quartz Commercial |
$4,192.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,870.05
|
| Rate for Payer: The Alliance Commercial |
$3,225.04
|
| Rate for Payer: WEA Trust Commercial |
$3,547.54
|
| Rate for Payer: WPS Commercial |
$4,777.40
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 7 4MM CEMENTED 1547-07-001
|
Facility
|
IP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,160.54 |
| Max. Negotiated Rate |
$5,934.07 |
| Rate for Payer: Aetna Commercial |
$5,805.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,418.54
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,934.07
|
| Rate for Payer: Health EOS Commercial |
$5,740.57
|
| Rate for Payer: HFN Commercial |
$5,934.07
|
| Rate for Payer: Multiplan Commercial |
$5,160.06
|
| Rate for Payer: Preferred Network Access Commercial |
$5,934.07
|
| Rate for Payer: Quartz Beloit One Network |
$3,160.54
|
| Rate for Payer: Quartz Commercial |
$3,870.05
|
| Rate for Payer: WEA Trust Commercial |
$3,547.54
|
| Rate for Payer: WPS Commercial |
$4,777.40
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 8 4MM CEMENTED 1547-08-001
|
Facility
|
OP
|
$5,963.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,736.43 |
| Max. Negotiated Rate |
$5,705.40 |
| Rate for Payer: Aetna Commercial |
$5,581.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.31
|
| Rate for Payer: Aetna Managed Medicare |
$1,736.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,030.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,100.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,976.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,286.81
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,705.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,470.47
|
| Rate for Payer: Health EOS Commercial |
$5,519.35
|
| Rate for Payer: HFN Commercial |
$5,705.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,651.14
|
| Rate for Payer: Multiplan Commercial |
$4,961.22
|
| Rate for Payer: NAPHCARE Commercial |
$3,720.91
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.74
|
| Rate for Payer: Quartz Commercial |
$4,030.99
|
| Rate for Payer: Quartz Medicare Advantage |
$3,720.91
|
| Rate for Payer: The Alliance Commercial |
$3,100.76
|
| Rate for Payer: WEA Trust Commercial |
$3,410.84
|
| Rate for Payer: WPS Commercial |
$4,593.30
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 8 4MM CEMENTED 1547-08-001
|
Facility
|
IP
|
$5,963.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,038.74 |
| Max. Negotiated Rate |
$5,705.40 |
| Rate for Payer: Aetna Commercial |
$5,581.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,286.81
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,705.40
|
| Rate for Payer: Health EOS Commercial |
$5,519.35
|
| Rate for Payer: HFN Commercial |
$5,705.40
|
| Rate for Payer: Multiplan Commercial |
$4,961.22
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.74
|
| Rate for Payer: Quartz Commercial |
$3,720.91
|
| Rate for Payer: WEA Trust Commercial |
$3,410.84
|
| Rate for Payer: WPS Commercial |
$4,593.30
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 8 8MM CEMENTED 1547-08-002
|
Facility
|
IP
|
$5,963.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,038.74 |
| Max. Negotiated Rate |
$5,705.40 |
| Rate for Payer: Aetna Commercial |
$5,581.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,286.81
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,705.40
|
| Rate for Payer: Health EOS Commercial |
$5,519.35
|
| Rate for Payer: HFN Commercial |
$5,705.40
|
| Rate for Payer: Multiplan Commercial |
$4,961.22
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.74
|
| Rate for Payer: Quartz Commercial |
$3,720.91
|
| Rate for Payer: WEA Trust Commercial |
$3,410.84
|
| Rate for Payer: WPS Commercial |
$4,593.30
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 8 8MM CEMENTED 1547-08-002
|
Facility
|
OP
|
$5,963.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,736.43 |
| Max. Negotiated Rate |
$5,705.40 |
| Rate for Payer: Aetna Commercial |
$5,581.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.31
|
| Rate for Payer: Aetna Managed Medicare |
$1,736.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,030.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,100.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,976.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,286.81
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,705.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,470.47
|
| Rate for Payer: Health EOS Commercial |
$5,519.35
|
| Rate for Payer: HFN Commercial |
$5,705.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,651.14
|
| Rate for Payer: Multiplan Commercial |
$4,961.22
|
| Rate for Payer: NAPHCARE Commercial |
$3,720.91
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.74
|
| Rate for Payer: Quartz Commercial |
$4,030.99
|
| Rate for Payer: Quartz Medicare Advantage |
$3,720.91
|
| Rate for Payer: The Alliance Commercial |
$3,100.76
|
| Rate for Payer: WEA Trust Commercial |
$3,410.84
|
| Rate for Payer: WPS Commercial |
$4,593.30
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 4 4MM CEMENTED 1549-04-001
|
Facility
|
OP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528746
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,658.07 |
| Max. Negotiated Rate |
$8,733.67 |
| Rate for Payer: Aetna Commercial |
$8,543.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,658.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,170.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,746.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,556.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.35
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,733.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,312.50
|
| Rate for Payer: Health EOS Commercial |
$8,448.88
|
| Rate for Payer: HFN Commercial |
$8,733.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,119.84
|
| Rate for Payer: Multiplan Commercial |
$7,594.50
|
| Rate for Payer: NAPHCARE Commercial |
$5,695.87
|
| Rate for Payer: Preferred Network Access Commercial |
$8,733.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.63
|
| Rate for Payer: Quartz Commercial |
$6,170.53
|
| Rate for Payer: Quartz Medicare Advantage |
$5,695.87
|
| Rate for Payer: The Alliance Commercial |
$4,746.56
|
| Rate for Payer: WEA Trust Commercial |
$5,221.22
|
| Rate for Payer: WPS Commercial |
$7,031.30
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 4 4MM CEMENTED 1549-04-001
|
Facility
|
IP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528746
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,651.63 |
| Max. Negotiated Rate |
$8,733.67 |
| Rate for Payer: Aetna Commercial |
$8,543.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.35
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,733.67
|
| Rate for Payer: Health EOS Commercial |
$8,448.88
|
| Rate for Payer: HFN Commercial |
$8,733.67
|
| Rate for Payer: Multiplan Commercial |
$7,594.50
|
| Rate for Payer: Preferred Network Access Commercial |
$8,733.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.63
|
| Rate for Payer: Quartz Commercial |
$5,695.87
|
| Rate for Payer: WEA Trust Commercial |
$5,221.22
|
| Rate for Payer: WPS Commercial |
$7,031.30
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 4 8MM CEMENTED 1549-04-002
|
Facility
|
IP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,651.63 |
| Max. Negotiated Rate |
$8,733.67 |
| Rate for Payer: Aetna Commercial |
$8,543.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.35
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,733.67
|
| Rate for Payer: Health EOS Commercial |
$8,448.88
|
| Rate for Payer: HFN Commercial |
$8,733.67
|
| Rate for Payer: Multiplan Commercial |
$7,594.50
|
| Rate for Payer: Preferred Network Access Commercial |
$8,733.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.63
|
| Rate for Payer: Quartz Commercial |
$5,695.87
|
| Rate for Payer: WEA Trust Commercial |
$5,221.22
|
| Rate for Payer: WPS Commercial |
$7,031.30
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 4 8MM CEMENTED 1549-04-002
|
Facility
|
OP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,658.07 |
| Max. Negotiated Rate |
$8,733.67 |
| Rate for Payer: Aetna Commercial |
$8,543.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,164.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,658.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,170.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,746.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,556.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,031.35
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,733.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,312.50
|
| Rate for Payer: Health EOS Commercial |
$8,448.88
|
| Rate for Payer: HFN Commercial |
$8,733.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,119.84
|
| Rate for Payer: Multiplan Commercial |
$7,594.50
|
| Rate for Payer: NAPHCARE Commercial |
$5,695.87
|
| Rate for Payer: Preferred Network Access Commercial |
$8,733.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.63
|
| Rate for Payer: Quartz Commercial |
$6,170.53
|
| Rate for Payer: Quartz Medicare Advantage |
$5,695.87
|
| Rate for Payer: The Alliance Commercial |
$4,746.56
|
| Rate for Payer: WEA Trust Commercial |
$5,221.22
|
| Rate for Payer: WPS Commercial |
$7,031.30
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 7 4MM CEMENTED 1549-07-001
|
Facility
|
IP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,160.54 |
| Max. Negotiated Rate |
$5,934.07 |
| Rate for Payer: Aetna Commercial |
$5,805.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,418.54
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,934.07
|
| Rate for Payer: Health EOS Commercial |
$5,740.57
|
| Rate for Payer: HFN Commercial |
$5,934.07
|
| Rate for Payer: Multiplan Commercial |
$5,160.06
|
| Rate for Payer: Preferred Network Access Commercial |
$5,934.07
|
| Rate for Payer: Quartz Beloit One Network |
$3,160.54
|
| Rate for Payer: Quartz Commercial |
$3,870.05
|
| Rate for Payer: WEA Trust Commercial |
$3,547.54
|
| Rate for Payer: WPS Commercial |
$4,777.40
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 7 4MM CEMENTED 1549-07-001
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,806.02 |
| Max. Negotiated Rate |
$5,934.07 |
| Rate for Payer: Aetna Commercial |
$5,805.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,806.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,192.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,225.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,096.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,418.54
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,934.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,609.56
|
| Rate for Payer: Health EOS Commercial |
$5,740.57
|
| Rate for Payer: HFN Commercial |
$5,934.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,837.56
|
| Rate for Payer: Multiplan Commercial |
$5,160.06
|
| Rate for Payer: NAPHCARE Commercial |
$3,870.05
|
| Rate for Payer: Preferred Network Access Commercial |
$5,934.07
|
| Rate for Payer: Quartz Beloit One Network |
$3,160.54
|
| Rate for Payer: Quartz Commercial |
$4,192.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,870.05
|
| Rate for Payer: The Alliance Commercial |
$3,225.04
|
| Rate for Payer: WEA Trust Commercial |
$3,547.54
|
| Rate for Payer: WPS Commercial |
$4,777.40
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 7 8MM CEMENTED 1549-07-002
|
Facility
|
IP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,160.54 |
| Max. Negotiated Rate |
$5,934.07 |
| Rate for Payer: Aetna Commercial |
$5,805.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,418.54
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,934.07
|
| Rate for Payer: Health EOS Commercial |
$5,740.57
|
| Rate for Payer: HFN Commercial |
$5,934.07
|
| Rate for Payer: Multiplan Commercial |
$5,160.06
|
| Rate for Payer: Preferred Network Access Commercial |
$5,934.07
|
| Rate for Payer: Quartz Beloit One Network |
$3,160.54
|
| Rate for Payer: Quartz Commercial |
$3,870.05
|
| Rate for Payer: WEA Trust Commercial |
$3,547.54
|
| Rate for Payer: WPS Commercial |
$4,777.40
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 7 8MM CEMENTED 1549-07-002
|
Facility
|
OP
|
$6,202.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,806.02 |
| Max. Negotiated Rate |
$5,934.07 |
| Rate for Payer: Aetna Commercial |
$5,805.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,806.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,192.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,225.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,096.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,418.54
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,934.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,609.56
|
| Rate for Payer: Health EOS Commercial |
$5,740.57
|
| Rate for Payer: HFN Commercial |
$5,934.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,837.56
|
| Rate for Payer: Multiplan Commercial |
$5,160.06
|
| Rate for Payer: NAPHCARE Commercial |
$3,870.05
|
| Rate for Payer: Preferred Network Access Commercial |
$5,934.07
|
| Rate for Payer: Quartz Beloit One Network |
$3,160.54
|
| Rate for Payer: Quartz Commercial |
$4,192.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,870.05
|
| Rate for Payer: The Alliance Commercial |
$3,225.04
|
| Rate for Payer: WEA Trust Commercial |
$3,547.54
|
| Rate for Payer: WPS Commercial |
$4,777.40
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 8 8MM CEMENTED 1549-08-002
|
Facility
|
IP
|
$5,963.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,038.74 |
| Max. Negotiated Rate |
$5,705.40 |
| Rate for Payer: Aetna Commercial |
$5,581.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,286.81
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,705.40
|
| Rate for Payer: Health EOS Commercial |
$5,519.35
|
| Rate for Payer: HFN Commercial |
$5,705.40
|
| Rate for Payer: Multiplan Commercial |
$4,961.22
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.74
|
| Rate for Payer: Quartz Commercial |
$3,720.91
|
| Rate for Payer: WEA Trust Commercial |
$3,410.84
|
| Rate for Payer: WPS Commercial |
$4,593.30
|
|
|
FEMORAL AUGMENT REVISION POSTERIOR ATTUNE SZ 8 8MM CEMENTED 1549-08-002
|
Facility
|
OP
|
$5,963.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831794
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,736.43 |
| Max. Negotiated Rate |
$5,705.40 |
| Rate for Payer: Aetna Commercial |
$5,581.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.31
|
| Rate for Payer: Aetna Managed Medicare |
$1,736.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,030.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,100.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,976.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,286.81
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,705.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,470.47
|
| Rate for Payer: Health EOS Commercial |
$5,519.35
|
| Rate for Payer: HFN Commercial |
$5,705.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,651.14
|
| Rate for Payer: Multiplan Commercial |
$4,961.22
|
| Rate for Payer: NAPHCARE Commercial |
$3,720.91
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.74
|
| Rate for Payer: Quartz Commercial |
$4,030.99
|
| Rate for Payer: Quartz Medicare Advantage |
$3,720.91
|
| Rate for Payer: The Alliance Commercial |
$3,100.76
|
| Rate for Payer: WEA Trust Commercial |
$3,410.84
|
| Rate for Payer: WPS Commercial |
$4,593.30
|
|
|
FEMORAL CANAL PRESSURIZER W/O HUB MEDIUM 0206-546-000
|
Facility
|
IP
|
$498.00
|
|
| Hospital Charge Code |
2963268
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$253.78 |
| Max. Negotiated Rate |
$476.49 |
| Rate for Payer: Aetna Commercial |
$466.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.50
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$476.49
|
| Rate for Payer: Health EOS Commercial |
$460.95
|
| Rate for Payer: HFN Commercial |
$476.49
|
| Rate for Payer: Multiplan Commercial |
$414.34
|
| Rate for Payer: Preferred Network Access Commercial |
$476.49
|
| Rate for Payer: Quartz Beloit One Network |
$253.78
|
| Rate for Payer: Quartz Commercial |
$310.75
|
| Rate for Payer: WEA Trust Commercial |
$284.86
|
| Rate for Payer: WPS Commercial |
$383.61
|
|
|
FEMORAL CANAL PRESSURIZER W/O HUB MEDIUM 0206-546-000
|
Facility
|
OP
|
$498.00
|
|
| Hospital Charge Code |
2963268
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$145.02 |
| Max. Negotiated Rate |
$476.49 |
| Rate for Payer: Aetna Commercial |
$466.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.41
|
| Rate for Payer: Aetna Managed Medicare |
$145.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$258.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$248.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.50
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$476.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.84
|
| Rate for Payer: Health EOS Commercial |
$460.95
|
| Rate for Payer: HFN Commercial |
$476.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$388.44
|
| Rate for Payer: Multiplan Commercial |
$414.34
|
| Rate for Payer: NAPHCARE Commercial |
$310.75
|
| Rate for Payer: Preferred Network Access Commercial |
$476.49
|
| Rate for Payer: Quartz Beloit One Network |
$253.78
|
| Rate for Payer: Quartz Commercial |
$336.65
|
| Rate for Payer: Quartz Medicare Advantage |
$310.75
|
| Rate for Payer: The Alliance Commercial |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$284.86
|
| Rate for Payer: WPS Commercial |
$383.61
|
|
|
FEMORAL CANAL PRESSURIZER W/O HUB SMALL 0206-545-000
|
Facility
|
IP
|
$498.00
|
|
| Hospital Charge Code |
2963803
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$253.78 |
| Max. Negotiated Rate |
$476.49 |
| Rate for Payer: Aetna Commercial |
$466.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.50
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$476.49
|
| Rate for Payer: Health EOS Commercial |
$460.95
|
| Rate for Payer: HFN Commercial |
$476.49
|
| Rate for Payer: Multiplan Commercial |
$414.34
|
| Rate for Payer: Preferred Network Access Commercial |
$476.49
|
| Rate for Payer: Quartz Beloit One Network |
$253.78
|
| Rate for Payer: Quartz Commercial |
$310.75
|
| Rate for Payer: WEA Trust Commercial |
$284.86
|
| Rate for Payer: WPS Commercial |
$383.61
|
|
|
FEMORAL CANAL PRESSURIZER W/O HUB SMALL 0206-545-000
|
Facility
|
OP
|
$498.00
|
|
| Hospital Charge Code |
2963803
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$145.02 |
| Max. Negotiated Rate |
$476.49 |
| Rate for Payer: Aetna Commercial |
$466.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.41
|
| Rate for Payer: Aetna Managed Medicare |
$145.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$258.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$248.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.50
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$476.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.84
|
| Rate for Payer: Health EOS Commercial |
$460.95
|
| Rate for Payer: HFN Commercial |
$476.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$388.44
|
| Rate for Payer: Multiplan Commercial |
$414.34
|
| Rate for Payer: NAPHCARE Commercial |
$310.75
|
| Rate for Payer: Preferred Network Access Commercial |
$476.49
|
| Rate for Payer: Quartz Beloit One Network |
$253.78
|
| Rate for Payer: Quartz Commercial |
$336.65
|
| Rate for Payer: Quartz Medicare Advantage |
$310.75
|
| Rate for Payer: The Alliance Commercial |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$284.86
|
| Rate for Payer: WPS Commercial |
$383.61
|
|
|
FEMORAL COMP C-LT LPS FLEX GSF 00-5764-013-51
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP C-LT LPS FLEX GSF 00-5764-013-51
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP C-RT LPS FLEX GSF 00-5764-013-52
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
FEMORAL COMP C-RT LPS FLEX GSF 00-5764-013-52
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
