|
FEMORAL FEMORAL BYPASS GRAFT
|
Facility
|
OP
|
$16,743.00
|
|
| Hospital Charge Code |
2960066
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,875.56 |
| Max. Negotiated Rate |
$16,019.70 |
| Rate for Payer: Aetna Commercial |
$15,671.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,974.94
|
| Rate for Payer: Aetna Managed Medicare |
$4,875.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,318.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,706.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,358.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,228.74
|
| Rate for Payer: Cash Price |
$5,022.90
|
| Rate for Payer: Cigna Commercial |
$16,019.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,744.43
|
| Rate for Payer: Health EOS Commercial |
$15,497.32
|
| Rate for Payer: HFN Commercial |
$16,019.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,059.54
|
| Rate for Payer: Multiplan Commercial |
$13,930.18
|
| Rate for Payer: NAPHCARE Commercial |
$10,447.63
|
| Rate for Payer: Preferred Network Access Commercial |
$16,019.70
|
| Rate for Payer: Quartz Beloit One Network |
$8,532.23
|
| Rate for Payer: Quartz Commercial |
$11,318.27
|
| Rate for Payer: Quartz Medicare Advantage |
$10,447.63
|
| Rate for Payer: The Alliance Commercial |
$8,706.36
|
| Rate for Payer: WEA Trust Commercial |
$9,577.00
|
| Rate for Payer: WPS Commercial |
$12,897.13
|
|
|
FEMORAL HEAD 22MM +0 8018-22-02
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 22MM +0 8018-22-02
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 22MM -2.0 8018-22-20
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 22MM -2.0 8018-22-20
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 22MM +3.0 8018-22-30
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 22MM +3.0 8018-22-30
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 32MM +0 8018-32-02
|
Facility
|
IP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967546
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,462.90 |
| Max. Negotiated Rate |
$4,624.21 |
| Rate for Payer: Aetna Commercial |
$4,523.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.95
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,624.21
|
| Rate for Payer: Health EOS Commercial |
$4,473.42
|
| Rate for Payer: HFN Commercial |
$4,624.21
|
| Rate for Payer: Multiplan Commercial |
$4,021.06
|
| Rate for Payer: Preferred Network Access Commercial |
$4,624.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.90
|
| Rate for Payer: Quartz Commercial |
$3,015.79
|
| Rate for Payer: WEA Trust Commercial |
$2,764.48
|
| Rate for Payer: WPS Commercial |
$3,722.86
|
|
|
FEMORAL HEAD 32MM +0 8018-32-02
|
Facility
|
OP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967546
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.37 |
| Max. Negotiated Rate |
$4,624.21 |
| Rate for Payer: Aetna Commercial |
$4,523.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,407.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,267.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,513.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,412.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.95
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,624.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,812.81
|
| Rate for Payer: Health EOS Commercial |
$4,473.42
|
| Rate for Payer: HFN Commercial |
$4,624.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,769.74
|
| Rate for Payer: Multiplan Commercial |
$4,021.06
|
| Rate for Payer: NAPHCARE Commercial |
$3,015.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,624.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.90
|
| Rate for Payer: Quartz Commercial |
$3,267.11
|
| Rate for Payer: Quartz Medicare Advantage |
$3,015.79
|
| Rate for Payer: The Alliance Commercial |
$2,513.16
|
| Rate for Payer: WEA Trust Commercial |
$2,764.48
|
| Rate for Payer: WPS Commercial |
$3,722.86
|
|
|
FEMORAL HEAD 32MM +10.5 8018-32-05
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 32MM +10.5 8018-32-05
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 32MM -3.5 8018-32-01
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3225465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 32MM -3.5 8018-32-01
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3225465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 32MM +3.5 8018-32-03
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967548
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 32MM +3.5 8018-32-03
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967548
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 32MM +7.0 8018-32-14
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 32MM +7.0 8018-32-14
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD 40MM +0
|
Facility
|
IP
|
$8,902.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,536.46 |
| Max. Negotiated Rate |
$8,517.43 |
| Rate for Payer: Aetna Commercial |
$8,332.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,961.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,906.78
|
| Rate for Payer: Cash Price |
$2,670.60
|
| Rate for Payer: Cigna Commercial |
$8,517.43
|
| Rate for Payer: Health EOS Commercial |
$8,239.69
|
| Rate for Payer: HFN Commercial |
$8,517.43
|
| Rate for Payer: Multiplan Commercial |
$7,406.46
|
| Rate for Payer: Preferred Network Access Commercial |
$8,517.43
|
| Rate for Payer: Quartz Beloit One Network |
$4,536.46
|
| Rate for Payer: Quartz Commercial |
$5,554.85
|
| Rate for Payer: WEA Trust Commercial |
$5,091.94
|
| Rate for Payer: WPS Commercial |
$6,857.21
|
|
|
FEMORAL HEAD 40MM +0
|
Facility
|
OP
|
$8,902.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,592.26 |
| Max. Negotiated Rate |
$8,517.43 |
| Rate for Payer: Aetna Commercial |
$8,332.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,961.95
|
| Rate for Payer: Aetna Managed Medicare |
$2,592.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,017.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,629.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,443.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,906.78
|
| Rate for Payer: Cash Price |
$2,670.60
|
| Rate for Payer: Cigna Commercial |
$8,517.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,180.96
|
| Rate for Payer: Health EOS Commercial |
$8,239.69
|
| Rate for Payer: HFN Commercial |
$8,517.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,943.56
|
| Rate for Payer: Multiplan Commercial |
$7,406.46
|
| Rate for Payer: NAPHCARE Commercial |
$5,554.85
|
| Rate for Payer: Preferred Network Access Commercial |
$8,517.43
|
| Rate for Payer: Quartz Beloit One Network |
$4,536.46
|
| Rate for Payer: Quartz Commercial |
$6,017.75
|
| Rate for Payer: Quartz Medicare Advantage |
$5,554.85
|
| Rate for Payer: The Alliance Commercial |
$4,629.04
|
| Rate for Payer: WEA Trust Commercial |
$5,091.94
|
| Rate for Payer: WPS Commercial |
$6,857.21
|
|
|
FEMORAL HEAD 40mm +3.5
|
Facility
|
IP
|
$8,912.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,541.56 |
| Max. Negotiated Rate |
$8,527.00 |
| Rate for Payer: Aetna Commercial |
$8,341.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,970.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,912.29
|
| Rate for Payer: Cash Price |
$2,673.60
|
| Rate for Payer: Cigna Commercial |
$8,527.00
|
| Rate for Payer: Health EOS Commercial |
$8,248.95
|
| Rate for Payer: HFN Commercial |
$8,527.00
|
| Rate for Payer: Multiplan Commercial |
$7,414.78
|
| Rate for Payer: Preferred Network Access Commercial |
$8,527.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,541.56
|
| Rate for Payer: Quartz Commercial |
$5,561.09
|
| Rate for Payer: WEA Trust Commercial |
$5,097.66
|
| Rate for Payer: WPS Commercial |
$6,864.91
|
|
|
FEMORAL HEAD 40mm +3.5
|
Facility
|
OP
|
$8,912.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,595.17 |
| Max. Negotiated Rate |
$8,527.00 |
| Rate for Payer: Aetna Commercial |
$8,341.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,970.89
|
| Rate for Payer: Aetna Managed Medicare |
$2,595.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,024.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,634.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,448.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,912.29
|
| Rate for Payer: Cash Price |
$2,673.60
|
| Rate for Payer: Cigna Commercial |
$8,527.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,186.78
|
| Rate for Payer: Health EOS Commercial |
$8,248.95
|
| Rate for Payer: HFN Commercial |
$8,527.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,951.36
|
| Rate for Payer: Multiplan Commercial |
$7,414.78
|
| Rate for Payer: NAPHCARE Commercial |
$5,561.09
|
| Rate for Payer: Preferred Network Access Commercial |
$8,527.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,541.56
|
| Rate for Payer: Quartz Commercial |
$6,024.51
|
| Rate for Payer: Quartz Medicare Advantage |
$5,561.09
|
| Rate for Payer: The Alliance Commercial |
$4,634.24
|
| Rate for Payer: WEA Trust Commercial |
$5,097.66
|
| Rate for Payer: WPS Commercial |
$6,864.91
|
|
|
FEMORAL HEAD ARTICUL/EZE 28MM +1.5 12/14 1365-11-000
|
Facility
|
IP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5490789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,124.01 |
| Max. Negotiated Rate |
$3,987.94 |
| Rate for Payer: Aetna Commercial |
$3,901.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,727.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,297.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,987.94
|
| Rate for Payer: Health EOS Commercial |
$3,857.90
|
| Rate for Payer: HFN Commercial |
$3,987.94
|
| Rate for Payer: Multiplan Commercial |
$3,467.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,987.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.01
|
| Rate for Payer: Quartz Commercial |
$2,600.83
|
| Rate for Payer: WEA Trust Commercial |
$2,384.10
|
| Rate for Payer: WPS Commercial |
$3,210.61
|
|
|
FEMORAL HEAD ARTICUL/EZE 28MM +1.5 12/14 1365-11-000
|
Facility
|
OP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5490789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,213.72 |
| Max. Negotiated Rate |
$3,987.94 |
| Rate for Payer: Aetna Commercial |
$3,901.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,727.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,213.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,817.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,167.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,080.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,297.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,987.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,425.78
|
| Rate for Payer: Health EOS Commercial |
$3,857.90
|
| Rate for Payer: HFN Commercial |
$3,987.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,251.04
|
| Rate for Payer: Multiplan Commercial |
$3,467.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,600.83
|
| Rate for Payer: Preferred Network Access Commercial |
$3,987.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.01
|
| Rate for Payer: Quartz Commercial |
$2,817.57
|
| Rate for Payer: Quartz Medicare Advantage |
$2,600.83
|
| Rate for Payer: The Alliance Commercial |
$2,167.36
|
| Rate for Payer: WEA Trust Commercial |
$2,384.10
|
| Rate for Payer: WPS Commercial |
$3,210.61
|
|
|
FEMORAL HEAD ARTICUL/EZE 28MM +5 12/14 1365-12-000
|
Facility
|
IP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5544766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,536.79 |
| Max. Negotiated Rate |
$4,762.95 |
| Rate for Payer: Aetna Commercial |
$4,659.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,452.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,743.87
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,762.95
|
| Rate for Payer: Health EOS Commercial |
$4,607.64
|
| Rate for Payer: HFN Commercial |
$4,762.95
|
| Rate for Payer: Multiplan Commercial |
$4,141.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,536.79
|
| Rate for Payer: Quartz Commercial |
$3,106.27
|
| Rate for Payer: WEA Trust Commercial |
$2,847.42
|
| Rate for Payer: WPS Commercial |
$3,834.55
|
|
|
FEMORAL HEAD ARTICUL/EZE 28MM +5 12/14 1365-12-000
|
Facility
|
OP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5544766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.59 |
| Max. Negotiated Rate |
$4,762.95 |
| Rate for Payer: Aetna Commercial |
$4,659.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,452.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,449.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,365.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,588.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,485.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,743.87
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,762.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,897.20
|
| Rate for Payer: Health EOS Commercial |
$4,607.64
|
| Rate for Payer: HFN Commercial |
$4,762.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,882.84
|
| Rate for Payer: Multiplan Commercial |
$4,141.70
|
| Rate for Payer: NAPHCARE Commercial |
$3,106.27
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,536.79
|
| Rate for Payer: Quartz Commercial |
$3,365.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,106.27
|
| Rate for Payer: The Alliance Commercial |
$2,588.56
|
| Rate for Payer: WEA Trust Commercial |
$2,847.42
|
| Rate for Payer: WPS Commercial |
$3,834.55
|
|
