|
FEMORAL HEAD ARTICUL/EZE 32MM +1.0 12/14 1365-21-000
|
Facility
|
OP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520945
|
|
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
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +1.0 12/14 1365-21-000
|
Facility
|
IP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520945
|
|
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 32MM +5 12/14 1365-22-000
|
Facility
|
OP
|
$5,170.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459308
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,505.50 |
| Max. Negotiated Rate |
$4,946.66 |
| Rate for Payer: Aetna Commercial |
$4,839.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,624.05
|
| Rate for Payer: Aetna Managed Medicare |
$1,505.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,494.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,688.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,580.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,849.70
|
| Rate for Payer: Cash Price |
$1,551.00
|
| Rate for Payer: Cigna Commercial |
$4,946.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,008.94
|
| Rate for Payer: Health EOS Commercial |
$4,785.35
|
| Rate for Payer: HFN Commercial |
$4,946.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,032.60
|
| Rate for Payer: Multiplan Commercial |
$4,301.44
|
| Rate for Payer: NAPHCARE Commercial |
$3,226.08
|
| Rate for Payer: Preferred Network Access Commercial |
$4,946.66
|
| Rate for Payer: Quartz Beloit One Network |
$2,634.63
|
| Rate for Payer: Quartz Commercial |
$3,494.92
|
| Rate for Payer: Quartz Medicare Advantage |
$3,226.08
|
| Rate for Payer: The Alliance Commercial |
$2,688.40
|
| Rate for Payer: WEA Trust Commercial |
$2,957.24
|
| Rate for Payer: WPS Commercial |
$3,982.45
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +5 12/14 1365-22-000
|
Facility
|
IP
|
$5,170.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459308
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,634.63 |
| Max. Negotiated Rate |
$4,946.66 |
| Rate for Payer: Aetna Commercial |
$4,839.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,624.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,849.70
|
| Rate for Payer: Cash Price |
$1,551.00
|
| Rate for Payer: Cigna Commercial |
$4,946.66
|
| Rate for Payer: Health EOS Commercial |
$4,785.35
|
| Rate for Payer: HFN Commercial |
$4,946.66
|
| Rate for Payer: Multiplan Commercial |
$4,301.44
|
| Rate for Payer: Preferred Network Access Commercial |
$4,946.66
|
| Rate for Payer: Quartz Beloit One Network |
$2,634.63
|
| Rate for Payer: Quartz Commercial |
$3,226.08
|
| Rate for Payer: WEA Trust Commercial |
$2,957.24
|
| Rate for Payer: WPS Commercial |
$3,982.45
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +9 12/14 1365-23-000
|
Facility
|
IP
|
$4,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.48 |
| Max. Negotiated Rate |
$3,834.85 |
| Rate for Payer: Aetna Commercial |
$3,751.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.21
|
| Rate for Payer: Cash Price |
$1,202.40
|
| Rate for Payer: Cigna Commercial |
$3,834.85
|
| Rate for Payer: Health EOS Commercial |
$3,709.80
|
| Rate for Payer: HFN Commercial |
$3,834.85
|
| Rate for Payer: Multiplan Commercial |
$3,334.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.48
|
| Rate for Payer: Quartz Commercial |
$2,500.99
|
| Rate for Payer: WEA Trust Commercial |
$2,292.58
|
| Rate for Payer: WPS Commercial |
$3,087.36
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +9 12/14 1365-23-000
|
Facility
|
OP
|
$4,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.13 |
| Max. Negotiated Rate |
$3,834.85 |
| Rate for Payer: Aetna Commercial |
$3,751.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.76
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,709.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,084.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,000.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.21
|
| Rate for Payer: Cash Price |
$1,202.40
|
| Rate for Payer: Cigna Commercial |
$3,834.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,332.66
|
| Rate for Payer: Health EOS Commercial |
$3,709.80
|
| Rate for Payer: HFN Commercial |
$3,834.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,126.24
|
| Rate for Payer: Multiplan Commercial |
$3,334.66
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.99
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.48
|
| Rate for Payer: Quartz Commercial |
$2,709.41
|
| Rate for Payer: Quartz Medicare Advantage |
$2,500.99
|
| Rate for Payer: The Alliance Commercial |
$2,084.16
|
| Rate for Payer: WEA Trust Commercial |
$2,292.58
|
| Rate for Payer: WPS Commercial |
$3,087.36
|
|
|
FEMORAL HEAD BIOLOX 40MM 6519-1-040
|
Facility
|
IP
|
$6,709.00
|
|
| Hospital Charge Code |
3779521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,418.91 |
| Max. Negotiated Rate |
$6,419.17 |
| Rate for Payer: Aetna Commercial |
$6,279.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,000.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,698.00
|
| Rate for Payer: Cash Price |
$2,012.70
|
| Rate for Payer: Cigna Commercial |
$6,419.17
|
| Rate for Payer: Health EOS Commercial |
$6,209.85
|
| Rate for Payer: HFN Commercial |
$6,419.17
|
| Rate for Payer: Multiplan Commercial |
$5,581.89
|
| Rate for Payer: Preferred Network Access Commercial |
$6,419.17
|
| Rate for Payer: Quartz Beloit One Network |
$3,418.91
|
| Rate for Payer: Quartz Commercial |
$4,186.42
|
| Rate for Payer: WEA Trust Commercial |
$3,837.55
|
| Rate for Payer: WPS Commercial |
$5,167.94
|
|
|
FEMORAL HEAD BIOLOX 40MM 6519-1-040
|
Facility
|
OP
|
$6,709.00
|
|
| Hospital Charge Code |
3779521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,953.66 |
| Max. Negotiated Rate |
$6,419.17 |
| Rate for Payer: Aetna Commercial |
$6,279.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,000.53
|
| Rate for Payer: Aetna Managed Medicare |
$1,953.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,535.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,488.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,349.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,698.00
|
| Rate for Payer: Cash Price |
$2,012.70
|
| Rate for Payer: Cigna Commercial |
$6,419.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,904.64
|
| Rate for Payer: Health EOS Commercial |
$6,209.85
|
| Rate for Payer: HFN Commercial |
$6,419.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,233.02
|
| Rate for Payer: Multiplan Commercial |
$5,581.89
|
| Rate for Payer: NAPHCARE Commercial |
$4,186.42
|
| Rate for Payer: Preferred Network Access Commercial |
$6,419.17
|
| Rate for Payer: Quartz Beloit One Network |
$3,418.91
|
| Rate for Payer: Quartz Commercial |
$4,535.28
|
| Rate for Payer: Quartz Medicare Advantage |
$4,186.42
|
| Rate for Payer: The Alliance Commercial |
$3,488.68
|
| Rate for Payer: WEA Trust Commercial |
$3,837.55
|
| Rate for Payer: WPS Commercial |
$5,167.94
|
|
|
FEMORAL HEAD BIOLOX 44MM 6519-1-044
|
Facility
|
IP
|
$6,709.00
|
|
| Hospital Charge Code |
4263461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,418.91 |
| Max. Negotiated Rate |
$6,419.17 |
| Rate for Payer: Aetna Commercial |
$6,279.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,000.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,698.00
|
| Rate for Payer: Cash Price |
$2,012.70
|
| Rate for Payer: Cigna Commercial |
$6,419.17
|
| Rate for Payer: Health EOS Commercial |
$6,209.85
|
| Rate for Payer: HFN Commercial |
$6,419.17
|
| Rate for Payer: Multiplan Commercial |
$5,581.89
|
| Rate for Payer: Preferred Network Access Commercial |
$6,419.17
|
| Rate for Payer: Quartz Beloit One Network |
$3,418.91
|
| Rate for Payer: Quartz Commercial |
$4,186.42
|
| Rate for Payer: WEA Trust Commercial |
$3,837.55
|
| Rate for Payer: WPS Commercial |
$5,167.94
|
|
|
FEMORAL HEAD BIOLOX 44MM 6519-1-044
|
Facility
|
OP
|
$6,709.00
|
|
| Hospital Charge Code |
4263461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,953.66 |
| Max. Negotiated Rate |
$6,419.17 |
| Rate for Payer: Aetna Commercial |
$6,279.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,000.53
|
| Rate for Payer: Aetna Managed Medicare |
$1,953.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,535.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,488.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,349.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,698.00
|
| Rate for Payer: Cash Price |
$2,012.70
|
| Rate for Payer: Cigna Commercial |
$6,419.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,904.64
|
| Rate for Payer: Health EOS Commercial |
$6,209.85
|
| Rate for Payer: HFN Commercial |
$6,419.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,233.02
|
| Rate for Payer: Multiplan Commercial |
$5,581.89
|
| Rate for Payer: NAPHCARE Commercial |
$4,186.42
|
| Rate for Payer: Preferred Network Access Commercial |
$6,419.17
|
| Rate for Payer: Quartz Beloit One Network |
$3,418.91
|
| Rate for Payer: Quartz Commercial |
$4,535.28
|
| Rate for Payer: Quartz Medicare Advantage |
$4,186.42
|
| Rate for Payer: The Alliance Commercial |
$3,488.68
|
| Rate for Payer: WEA Trust Commercial |
$3,837.55
|
| Rate for Payer: WPS Commercial |
$5,167.94
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 32MM +1.0 12/14 1365-32-310
|
Facility
|
IP
|
$5,850.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563227
|
|
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
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 32MM +1.0 12/14 1365-32-310
|
Facility
|
OP
|
$5,850.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563227
|
|
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
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 32MM +5.0 12/14 1365-32-320
|
Facility
|
OP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,611.21 |
| Max. Negotiated Rate |
$5,293.97 |
| Rate for Payer: Aetna Commercial |
$5,178.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,948.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,611.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,740.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,877.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,762.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.79
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,293.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,220.21
|
| Rate for Payer: Health EOS Commercial |
$5,121.34
|
| Rate for Payer: HFN Commercial |
$5,293.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,315.74
|
| Rate for Payer: Multiplan Commercial |
$4,603.46
|
| Rate for Payer: NAPHCARE Commercial |
$3,452.59
|
| Rate for Payer: Preferred Network Access Commercial |
$5,293.97
|
| Rate for Payer: Quartz Beloit One Network |
$2,819.62
|
| Rate for Payer: Quartz Commercial |
$3,740.31
|
| Rate for Payer: Quartz Medicare Advantage |
$3,452.59
|
| Rate for Payer: The Alliance Commercial |
$2,877.16
|
| Rate for Payer: WEA Trust Commercial |
$3,164.88
|
| Rate for Payer: WPS Commercial |
$4,262.07
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 32MM +5.0 12/14 1365-32-320
|
Facility
|
IP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,819.62 |
| Max. Negotiated Rate |
$5,293.97 |
| Rate for Payer: Aetna Commercial |
$5,178.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,948.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.79
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,293.97
|
| Rate for Payer: Health EOS Commercial |
$5,121.34
|
| Rate for Payer: HFN Commercial |
$5,293.97
|
| Rate for Payer: Multiplan Commercial |
$4,603.46
|
| Rate for Payer: Preferred Network Access Commercial |
$5,293.97
|
| Rate for Payer: Quartz Beloit One Network |
$2,819.62
|
| Rate for Payer: Quartz Commercial |
$3,452.59
|
| Rate for Payer: WEA Trust Commercial |
$3,164.88
|
| Rate for Payer: WPS Commercial |
$4,262.07
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +12 12/14 1365-36-340
|
Facility
|
IP
|
$6,064.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217129
|
|
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
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +12 12/14 1365-36-340
|
Facility
|
OP
|
$6,064.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217129
|
|
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
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +1.5 12/14 1365-36-310
|
Facility
|
IP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,927.14 |
| Max. Negotiated Rate |
$5,495.86 |
| Rate for Payer: Aetna Commercial |
$5,376.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,137.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,166.09
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,495.86
|
| Rate for Payer: Health EOS Commercial |
$5,316.65
|
| Rate for Payer: HFN Commercial |
$5,495.86
|
| Rate for Payer: Multiplan Commercial |
$4,779.01
|
| Rate for Payer: Preferred Network Access Commercial |
$5,495.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,927.14
|
| Rate for Payer: Quartz Commercial |
$3,584.26
|
| Rate for Payer: WEA Trust Commercial |
$3,285.57
|
| Rate for Payer: WPS Commercial |
$4,424.60
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +1.5 12/14 1365-36-310
|
Facility
|
OP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,672.65 |
| Max. Negotiated Rate |
$5,495.86 |
| Rate for Payer: Aetna Commercial |
$5,376.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,137.43
|
| Rate for Payer: Aetna Managed Medicare |
$1,672.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,882.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,986.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,867.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,166.09
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,495.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,343.01
|
| Rate for Payer: Health EOS Commercial |
$5,316.65
|
| Rate for Payer: HFN Commercial |
$5,495.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,480.32
|
| Rate for Payer: Multiplan Commercial |
$4,779.01
|
| Rate for Payer: NAPHCARE Commercial |
$3,584.26
|
| Rate for Payer: Preferred Network Access Commercial |
$5,495.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,927.14
|
| Rate for Payer: Quartz Commercial |
$3,882.94
|
| Rate for Payer: Quartz Medicare Advantage |
$3,584.26
|
| Rate for Payer: The Alliance Commercial |
$2,986.88
|
| Rate for Payer: WEA Trust Commercial |
$3,285.57
|
| Rate for Payer: WPS Commercial |
$4,424.60
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +5 12/14 1365-36-320
|
Facility
|
OP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,672.65 |
| Max. Negotiated Rate |
$5,495.86 |
| Rate for Payer: Aetna Commercial |
$5,376.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,137.43
|
| Rate for Payer: Aetna Managed Medicare |
$1,672.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,882.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,986.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,867.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,166.09
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,495.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,343.01
|
| Rate for Payer: Health EOS Commercial |
$5,316.65
|
| Rate for Payer: HFN Commercial |
$5,495.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,480.32
|
| Rate for Payer: Multiplan Commercial |
$4,779.01
|
| Rate for Payer: NAPHCARE Commercial |
$3,584.26
|
| Rate for Payer: Preferred Network Access Commercial |
$5,495.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,927.14
|
| Rate for Payer: Quartz Commercial |
$3,882.94
|
| Rate for Payer: Quartz Medicare Advantage |
$3,584.26
|
| Rate for Payer: The Alliance Commercial |
$2,986.88
|
| Rate for Payer: WEA Trust Commercial |
$3,285.57
|
| Rate for Payer: WPS Commercial |
$4,424.60
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +5 12/14 1365-36-320
|
Facility
|
IP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,927.14 |
| Max. Negotiated Rate |
$5,495.86 |
| Rate for Payer: Aetna Commercial |
$5,376.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,137.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,166.09
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,495.86
|
| Rate for Payer: Health EOS Commercial |
$5,316.65
|
| Rate for Payer: HFN Commercial |
$5,495.86
|
| Rate for Payer: Multiplan Commercial |
$4,779.01
|
| Rate for Payer: Preferred Network Access Commercial |
$5,495.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,927.14
|
| Rate for Payer: Quartz Commercial |
$3,584.26
|
| Rate for Payer: WEA Trust Commercial |
$3,285.57
|
| Rate for Payer: WPS Commercial |
$4,424.60
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +8.5 12/14 1365-36-330
|
Facility
|
IP
|
$5,320.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563290
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.07 |
| Max. Negotiated Rate |
$5,090.18 |
| Rate for Payer: Aetna Commercial |
$4,979.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.38
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cigna Commercial |
$5,090.18
|
| Rate for Payer: Health EOS Commercial |
$4,924.19
|
| Rate for Payer: HFN Commercial |
$5,090.18
|
| Rate for Payer: Multiplan Commercial |
$4,426.24
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.18
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.07
|
| Rate for Payer: Quartz Commercial |
$3,319.68
|
| Rate for Payer: WEA Trust Commercial |
$3,043.04
|
| Rate for Payer: WPS Commercial |
$4,098.00
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +8.5 12/14 1365-36-330
|
Facility
|
OP
|
$5,320.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563290
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,549.18 |
| Max. Negotiated Rate |
$5,090.18 |
| Rate for Payer: Aetna Commercial |
$4,979.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.21
|
| Rate for Payer: Aetna Managed Medicare |
$1,549.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,596.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,766.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,655.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.38
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cigna Commercial |
$5,090.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,096.24
|
| Rate for Payer: Health EOS Commercial |
$4,924.19
|
| Rate for Payer: HFN Commercial |
$5,090.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,149.60
|
| Rate for Payer: Multiplan Commercial |
$4,426.24
|
| Rate for Payer: NAPHCARE Commercial |
$3,319.68
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.18
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.07
|
| Rate for Payer: Quartz Commercial |
$3,596.32
|
| Rate for Payer: Quartz Medicare Advantage |
$3,319.68
|
| Rate for Payer: The Alliance Commercial |
$2,766.40
|
| Rate for Payer: WEA Trust Commercial |
$3,043.04
|
| Rate for Payer: WPS Commercial |
$4,098.00
|
|
|
FEMORAL HEAD BIOLOX CERAMIC REVISION 36MM +5 12/14 1365-36-720
|
Facility
|
IP
|
$5,397.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5767774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,750.31 |
| Max. Negotiated Rate |
$5,163.85 |
| Rate for Payer: Aetna Commercial |
$5,051.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,827.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,974.83
|
| Rate for Payer: Cash Price |
$1,619.10
|
| Rate for Payer: Cigna Commercial |
$5,163.85
|
| Rate for Payer: Health EOS Commercial |
$4,995.46
|
| Rate for Payer: HFN Commercial |
$5,163.85
|
| Rate for Payer: Multiplan Commercial |
$4,490.30
|
| Rate for Payer: Preferred Network Access Commercial |
$5,163.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,750.31
|
| Rate for Payer: Quartz Commercial |
$3,367.73
|
| Rate for Payer: WEA Trust Commercial |
$3,087.08
|
| Rate for Payer: WPS Commercial |
$4,157.31
|
|
|
FEMORAL HEAD BIOLOX CERAMIC REVISION 36MM +5 12/14 1365-36-720
|
Facility
|
OP
|
$5,397.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5767774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.61 |
| Max. Negotiated Rate |
$5,163.85 |
| Rate for Payer: Aetna Commercial |
$5,051.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,827.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,571.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,648.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,806.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,694.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,974.83
|
| Rate for Payer: Cash Price |
$1,619.10
|
| Rate for Payer: Cigna Commercial |
$5,163.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,141.05
|
| Rate for Payer: Health EOS Commercial |
$4,995.46
|
| Rate for Payer: HFN Commercial |
$5,163.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,209.66
|
| Rate for Payer: Multiplan Commercial |
$4,490.30
|
| Rate for Payer: NAPHCARE Commercial |
$3,367.73
|
| Rate for Payer: Preferred Network Access Commercial |
$5,163.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,750.31
|
| Rate for Payer: Quartz Commercial |
$3,648.37
|
| Rate for Payer: Quartz Medicare Advantage |
$3,367.73
|
| Rate for Payer: The Alliance Commercial |
$2,806.44
|
| Rate for Payer: WEA Trust Commercial |
$3,087.08
|
| Rate for Payer: WPS Commercial |
$4,157.31
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 28MM +3MM 650-1157
|
Facility
|
IP
|
$5,255.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,677.95 |
| Max. Negotiated Rate |
$5,027.98 |
| Rate for Payer: Aetna Commercial |
$4,918.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,700.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,896.56
|
| Rate for Payer: Cash Price |
$1,576.50
|
| Rate for Payer: Cigna Commercial |
$5,027.98
|
| Rate for Payer: Health EOS Commercial |
$4,864.03
|
| Rate for Payer: HFN Commercial |
$5,027.98
|
| Rate for Payer: Multiplan Commercial |
$4,372.16
|
| Rate for Payer: Preferred Network Access Commercial |
$5,027.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,677.95
|
| Rate for Payer: Quartz Commercial |
$3,279.12
|
| Rate for Payer: WEA Trust Commercial |
$3,005.86
|
| Rate for Payer: WPS Commercial |
$4,047.93
|
|
