|
Felbamate Level
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
977949
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$145.50
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
Felbamate Level
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
977949
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
Felbamate Level
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
977949
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna Commercial |
$184.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$184.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$97.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$176.54
|
| Rate for Payer: HFN Commercial |
$184.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: Preferred Network Access Commercial |
$184.30
|
| Rate for Payer: Quartz Beloit One Network |
$85.36
|
| Rate for Payer: Quartz Commercial |
$110.58
|
| Rate for Payer: The Alliance Commercial |
$97.00
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$37,671.00
|
|
|
Service Code
|
MSDRG 748
|
| Min. Negotiated Rate |
$13,550.74 |
| Max. Negotiated Rate |
$37,671.00 |
| Rate for Payer: Aetna Managed Medicare |
$13,550.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,372.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,513.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,389.20
|
| Rate for Payer: Anthem Medicare Advantage |
$13,550.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,550.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,550.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,550.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,743.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,550.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,395.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,550.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,550.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,550.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,550.74
|
| Rate for Payer: NAPHCARE Commercial |
$20,326.11
|
| Rate for Payer: Quartz Medicare Advantage |
$13,550.74
|
| Rate for Payer: The Alliance Commercial |
$37,671.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,550.74
|
| Rate for Payer: United Healthcare PPO |
$21,327.79
|
| Rate for Payer: Wellcare Medicare |
$13,550.74
|
|
|
FEM COMP C-RT LPS FLEX 5960-13-52
|
Facility
|
IP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,113.02 |
| Max. Negotiated Rate |
$17,110.16 |
| Rate for Payer: Aetna Commercial |
$16,738.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,994.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,856.94
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,110.16
|
| Rate for Payer: Health EOS Commercial |
$16,552.22
|
| Rate for Payer: HFN Commercial |
$17,110.16
|
| Rate for Payer: Multiplan Commercial |
$14,878.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,158.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,110.16
|
| Rate for Payer: Quartz Beloit One Network |
$9,113.02
|
| Rate for Payer: Quartz Commercial |
$11,158.80
|
| Rate for Payer: WEA Trust Commercial |
$10,228.90
|
| Rate for Payer: WPS Commercial |
$13,775.54
|
|
|
FEM COMP C-RT LPS FLEX 5960-13-52
|
Facility
|
OP
|
$18,598.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,207.44 |
| Max. Negotiated Rate |
$74,392.00 |
| Rate for Payer: Aetna Commercial |
$16,738.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,994.28
|
| Rate for Payer: Aetna Managed Medicare |
$5,207.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,088.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,927.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,856.94
|
| Rate for Payer: Cash Price |
$5,579.40
|
| Rate for Payer: Cigna Commercial |
$17,110.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,407.44
|
| Rate for Payer: Health EOS Commercial |
$16,552.22
|
| Rate for Payer: HFN Commercial |
$17,110.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,948.50
|
| Rate for Payer: Multiplan Commercial |
$14,878.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,158.80
|
| Rate for Payer: Preferred Network Access Commercial |
$17,110.16
|
| Rate for Payer: Quartz Beloit One Network |
$9,113.02
|
| Rate for Payer: Quartz Commercial |
$12,088.70
|
| Rate for Payer: Quartz Medicare Advantage |
$11,158.80
|
| Rate for Payer: The Alliance Commercial |
$74,392.00
|
| Rate for Payer: WEA Trust Commercial |
$10,228.90
|
| Rate for Payer: WPS Commercial |
$13,775.54
|
|
|
FEM COMPONENT D RT TI-NIDIUM
|
Facility
|
IP
|
$22,629.00
|
|
| Hospital Charge Code |
2967466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,088.21 |
| Max. Negotiated Rate |
$20,818.68 |
| Rate for Payer: Aetna Commercial |
$20,366.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,460.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,993.37
|
| Rate for Payer: Cash Price |
$6,788.70
|
| Rate for Payer: Cigna Commercial |
$20,818.68
|
| Rate for Payer: Health EOS Commercial |
$20,139.81
|
| Rate for Payer: HFN Commercial |
$20,818.68
|
| Rate for Payer: Multiplan Commercial |
$18,103.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,577.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,818.68
|
| Rate for Payer: Quartz Beloit One Network |
$11,088.21
|
| Rate for Payer: Quartz Commercial |
$13,577.40
|
| Rate for Payer: WEA Trust Commercial |
$12,445.95
|
| Rate for Payer: WPS Commercial |
$16,761.30
|
|
|
FEM COMPONENT D RT TI-NIDIUM
|
Facility
|
OP
|
$22,629.00
|
|
| Hospital Charge Code |
2967466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,336.12 |
| Max. Negotiated Rate |
$90,516.00 |
| Rate for Payer: Aetna Commercial |
$20,366.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,460.94
|
| Rate for Payer: Aetna Managed Medicare |
$6,336.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,708.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,314.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,861.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,993.37
|
| Rate for Payer: Cash Price |
$6,788.70
|
| Rate for Payer: Cigna Commercial |
$20,818.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,663.19
|
| Rate for Payer: Health EOS Commercial |
$20,139.81
|
| Rate for Payer: HFN Commercial |
$20,818.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,971.75
|
| Rate for Payer: Multiplan Commercial |
$18,103.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,577.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,818.68
|
| Rate for Payer: Quartz Beloit One Network |
$11,088.21
|
| Rate for Payer: Quartz Commercial |
$14,708.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13,577.40
|
| Rate for Payer: The Alliance Commercial |
$90,516.00
|
| Rate for Payer: WEA Trust Commercial |
$12,445.95
|
| Rate for Payer: WPS Commercial |
$16,761.30
|
|
|
FEM HEAD VERSYS 36MM -3.5 8018-36-01
|
Facility
|
OP
|
$9,076.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3227468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,541.28 |
| Max. Negotiated Rate |
$36,304.00 |
| Rate for Payer: Aetna Commercial |
$8,168.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,805.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,541.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,899.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,538.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,356.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,810.28
|
| Rate for Payer: Cash Price |
$2,722.80
|
| Rate for Payer: Cigna Commercial |
$8,349.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,078.93
|
| Rate for Payer: Health EOS Commercial |
$8,077.64
|
| Rate for Payer: HFN Commercial |
$8,349.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,807.00
|
| Rate for Payer: Multiplan Commercial |
$7,260.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,445.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,349.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,447.24
|
| Rate for Payer: Quartz Commercial |
$5,899.40
|
| Rate for Payer: Quartz Medicare Advantage |
$5,445.60
|
| Rate for Payer: The Alliance Commercial |
$36,304.00
|
| Rate for Payer: WEA Trust Commercial |
$4,991.80
|
| Rate for Payer: WPS Commercial |
$6,722.59
|
|
|
FEM HEAD VERSYS 36MM -3.5 8018-36-01
|
Facility
|
IP
|
$9,076.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3227468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,447.24 |
| Max. Negotiated Rate |
$8,349.92 |
| Rate for Payer: Aetna Commercial |
$8,168.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,805.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,810.28
|
| Rate for Payer: Cash Price |
$2,722.80
|
| Rate for Payer: Cigna Commercial |
$8,349.92
|
| Rate for Payer: Health EOS Commercial |
$8,077.64
|
| Rate for Payer: HFN Commercial |
$8,349.92
|
| Rate for Payer: Multiplan Commercial |
$7,260.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,445.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,349.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,447.24
|
| Rate for Payer: Quartz Commercial |
$5,445.60
|
| Rate for Payer: WEA Trust Commercial |
$4,991.80
|
| Rate for Payer: WPS Commercial |
$6,722.59
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 4 4MM CEMENTED 1547-04-001
|
Facility
|
OP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,555.84 |
| Max. Negotiated Rate |
$36,512.00 |
| Rate for Payer: Aetna Commercial |
$8,215.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,850.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,555.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,933.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,564.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,381.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,837.84
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,397.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,108.03
|
| Rate for Payer: Health EOS Commercial |
$8,123.92
|
| Rate for Payer: HFN Commercial |
$8,397.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,846.00
|
| Rate for Payer: Multiplan Commercial |
$7,302.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,397.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,472.72
|
| Rate for Payer: Quartz Commercial |
$5,933.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,476.80
|
| Rate for Payer: The Alliance Commercial |
$36,512.00
|
| Rate for Payer: WEA Trust Commercial |
$5,020.40
|
| Rate for Payer: WPS Commercial |
$6,761.11
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 4 4MM CEMENTED 1547-04-001
|
Facility
|
IP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,472.72 |
| Max. Negotiated Rate |
$8,397.76 |
| Rate for Payer: Aetna Commercial |
$8,215.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,850.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,837.84
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,397.76
|
| Rate for Payer: Health EOS Commercial |
$8,123.92
|
| Rate for Payer: HFN Commercial |
$8,397.76
|
| Rate for Payer: Multiplan Commercial |
$7,302.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,397.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,472.72
|
| Rate for Payer: Quartz Commercial |
$5,476.80
|
| Rate for Payer: WEA Trust Commercial |
$5,020.40
|
| Rate for Payer: WPS Commercial |
$6,761.11
|
|
|
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 |
$4,472.72 |
| Max. Negotiated Rate |
$8,397.76 |
| Rate for Payer: Aetna Commercial |
$8,215.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,850.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,837.84
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,397.76
|
| Rate for Payer: Health EOS Commercial |
$8,123.92
|
| Rate for Payer: HFN Commercial |
$8,397.76
|
| Rate for Payer: Multiplan Commercial |
$7,302.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,397.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,472.72
|
| Rate for Payer: Quartz Commercial |
$5,476.80
|
| Rate for Payer: WEA Trust Commercial |
$5,020.40
|
| Rate for Payer: WPS Commercial |
$6,761.11
|
|
|
FEMORAL AUGMENT REVISION DISTAL ATTUNE SZ 4 8MM CEMENTED 1547-04-002
|
Facility
|
OP
|
$9,128.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,555.84 |
| Max. Negotiated Rate |
$36,512.00 |
| Rate for Payer: Aetna Commercial |
$8,215.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,850.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,555.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,933.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,564.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,381.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,837.84
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,397.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,108.03
|
| Rate for Payer: Health EOS Commercial |
$8,123.92
|
| Rate for Payer: HFN Commercial |
$8,397.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,846.00
|
| Rate for Payer: Multiplan Commercial |
$7,302.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,397.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,472.72
|
| Rate for Payer: Quartz Commercial |
$5,933.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,476.80
|
| Rate for Payer: The Alliance Commercial |
$36,512.00
|
| Rate for Payer: WEA Trust Commercial |
$5,020.40
|
| Rate for Payer: WPS Commercial |
$6,761.11
|
|
|
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 |
$1,736.56 |
| Max. Negotiated Rate |
$24,808.00 |
| Rate for Payer: Aetna Commercial |
$5,581.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,736.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,031.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,976.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.06
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,705.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,470.64
|
| Rate for Payer: Health EOS Commercial |
$5,519.78
|
| Rate for Payer: HFN Commercial |
$5,705.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,651.50
|
| Rate for Payer: Multiplan Commercial |
$4,961.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,721.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.98
|
| Rate for Payer: Quartz Commercial |
$4,031.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,721.20
|
| Rate for Payer: The Alliance Commercial |
$24,808.00
|
| Rate for Payer: WEA Trust Commercial |
$3,411.10
|
| Rate for Payer: WPS Commercial |
$4,593.82
|
|
|
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 |
$3,038.98 |
| Max. Negotiated Rate |
$5,705.84 |
| Rate for Payer: Aetna Commercial |
$5,581.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.06
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,705.84
|
| Rate for Payer: Health EOS Commercial |
$5,519.78
|
| Rate for Payer: HFN Commercial |
$5,705.84
|
| Rate for Payer: Multiplan Commercial |
$4,961.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,721.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.98
|
| Rate for Payer: Quartz Commercial |
$3,721.20
|
| Rate for Payer: WEA Trust Commercial |
$3,411.10
|
| Rate for Payer: WPS Commercial |
$4,593.82
|
|
|
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 |
$1,669.64 |
| Max. Negotiated Rate |
$23,852.00 |
| Rate for Payer: Aetna Commercial |
$5,366.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,128.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,669.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,875.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,981.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,862.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,160.39
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,485.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,336.89
|
| Rate for Payer: Health EOS Commercial |
$5,307.07
|
| Rate for Payer: HFN Commercial |
$5,485.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,472.25
|
| Rate for Payer: Multiplan Commercial |
$4,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,485.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,921.87
|
| Rate for Payer: Quartz Commercial |
$3,875.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,577.80
|
| Rate for Payer: The Alliance Commercial |
$23,852.00
|
| Rate for Payer: WEA Trust Commercial |
$3,279.65
|
| Rate for Payer: WPS Commercial |
$4,416.79
|
|
|
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 |
$2,921.87 |
| Max. Negotiated Rate |
$5,485.96 |
| Rate for Payer: Aetna Commercial |
$5,366.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,128.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,160.39
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,485.96
|
| Rate for Payer: Health EOS Commercial |
$5,307.07
|
| Rate for Payer: HFN Commercial |
$5,485.96
|
| Rate for Payer: Multiplan Commercial |
$4,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,485.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,921.87
|
| Rate for Payer: Quartz Commercial |
$3,577.80
|
| Rate for Payer: WEA Trust Commercial |
$3,279.65
|
| Rate for Payer: WPS Commercial |
$4,416.79
|
|
|
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 |
$2,921.87 |
| Max. Negotiated Rate |
$5,485.96 |
| Rate for Payer: Aetna Commercial |
$5,366.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,128.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,160.39
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,485.96
|
| Rate for Payer: Health EOS Commercial |
$5,307.07
|
| Rate for Payer: HFN Commercial |
$5,485.96
|
| Rate for Payer: Multiplan Commercial |
$4,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,485.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,921.87
|
| Rate for Payer: Quartz Commercial |
$3,577.80
|
| Rate for Payer: WEA Trust Commercial |
$3,279.65
|
| Rate for Payer: WPS Commercial |
$4,416.79
|
|
|
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 |
$1,669.64 |
| Max. Negotiated Rate |
$23,852.00 |
| Rate for Payer: Aetna Commercial |
$5,366.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,128.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,669.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,875.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,981.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,862.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,160.39
|
| Rate for Payer: Cash Price |
$1,788.90
|
| Rate for Payer: Cigna Commercial |
$5,485.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,336.89
|
| Rate for Payer: Health EOS Commercial |
$5,307.07
|
| Rate for Payer: HFN Commercial |
$5,485.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,472.25
|
| Rate for Payer: Multiplan Commercial |
$4,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,577.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,485.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,921.87
|
| Rate for Payer: Quartz Commercial |
$3,875.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,577.80
|
| Rate for Payer: The Alliance Commercial |
$23,852.00
|
| Rate for Payer: WEA Trust Commercial |
$3,279.65
|
| Rate for Payer: WPS Commercial |
$4,416.79
|
|
|
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 |
$4,472.72 |
| Max. Negotiated Rate |
$8,397.76 |
| Rate for Payer: Aetna Commercial |
$8,215.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,850.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,837.84
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,397.76
|
| Rate for Payer: Health EOS Commercial |
$8,123.92
|
| Rate for Payer: HFN Commercial |
$8,397.76
|
| Rate for Payer: Multiplan Commercial |
$7,302.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,397.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,472.72
|
| Rate for Payer: Quartz Commercial |
$5,476.80
|
| Rate for Payer: WEA Trust Commercial |
$5,020.40
|
| Rate for Payer: WPS Commercial |
$6,761.11
|
|
|
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 |
$2,555.84 |
| Max. Negotiated Rate |
$36,512.00 |
| Rate for Payer: Aetna Commercial |
$8,215.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,850.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,555.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,933.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,564.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,381.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,837.84
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,397.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,108.03
|
| Rate for Payer: Health EOS Commercial |
$8,123.92
|
| Rate for Payer: HFN Commercial |
$8,397.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,846.00
|
| Rate for Payer: Multiplan Commercial |
$7,302.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,397.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,472.72
|
| Rate for Payer: Quartz Commercial |
$5,933.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,476.80
|
| Rate for Payer: The Alliance Commercial |
$36,512.00
|
| Rate for Payer: WEA Trust Commercial |
$5,020.40
|
| Rate for Payer: WPS Commercial |
$6,761.11
|
|
|
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 |
$4,472.72 |
| Max. Negotiated Rate |
$8,397.76 |
| Rate for Payer: Aetna Commercial |
$8,215.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,850.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,837.84
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,397.76
|
| Rate for Payer: Health EOS Commercial |
$8,123.92
|
| Rate for Payer: HFN Commercial |
$8,397.76
|
| Rate for Payer: Multiplan Commercial |
$7,302.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,397.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,472.72
|
| Rate for Payer: Quartz Commercial |
$5,476.80
|
| Rate for Payer: WEA Trust Commercial |
$5,020.40
|
| Rate for Payer: WPS Commercial |
$6,761.11
|
|
|
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 |
$2,555.84 |
| Max. Negotiated Rate |
$36,512.00 |
| Rate for Payer: Aetna Commercial |
$8,215.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,850.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,555.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,933.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,564.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,381.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,837.84
|
| Rate for Payer: Cash Price |
$2,738.40
|
| Rate for Payer: Cigna Commercial |
$8,397.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,108.03
|
| Rate for Payer: Health EOS Commercial |
$8,123.92
|
| Rate for Payer: HFN Commercial |
$8,397.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,846.00
|
| Rate for Payer: Multiplan Commercial |
$7,302.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,476.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,397.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,472.72
|
| Rate for Payer: Quartz Commercial |
$5,933.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,476.80
|
| Rate for Payer: The Alliance Commercial |
$36,512.00
|
| Rate for Payer: WEA Trust Commercial |
$5,020.40
|
| Rate for Payer: WPS Commercial |
$6,761.11
|
|
|
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 |
$3,038.98 |
| Max. Negotiated Rate |
$5,705.84 |
| Rate for Payer: Aetna Commercial |
$5,581.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,333.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.06
|
| Rate for Payer: Cash Price |
$1,860.60
|
| Rate for Payer: Cigna Commercial |
$5,705.84
|
| Rate for Payer: Health EOS Commercial |
$5,519.78
|
| Rate for Payer: HFN Commercial |
$5,705.84
|
| Rate for Payer: Multiplan Commercial |
$4,961.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,721.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,705.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,038.98
|
| Rate for Payer: Quartz Commercial |
$3,721.20
|
| Rate for Payer: WEA Trust Commercial |
$3,411.10
|
| Rate for Payer: WPS Commercial |
$4,593.82
|
|
