|
FEMORAL HEAD BIOLOX DELTA CERAMIC 36MM +7MM 00-8775-036-04
|
Facility
|
IP
|
$7,948.00
|
|
| Hospital Charge Code |
4230460
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,050.30 |
| Max. Negotiated Rate |
$7,604.65 |
| Rate for Payer: Aetna Commercial |
$7,439.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,108.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,380.94
|
| Rate for Payer: Cash Price |
$2,384.40
|
| Rate for Payer: Cigna Commercial |
$7,604.65
|
| Rate for Payer: Health EOS Commercial |
$7,356.67
|
| Rate for Payer: HFN Commercial |
$7,604.65
|
| Rate for Payer: Multiplan Commercial |
$6,612.74
|
| Rate for Payer: Preferred Network Access Commercial |
$7,604.65
|
| Rate for Payer: Quartz Beloit One Network |
$4,050.30
|
| Rate for Payer: Quartz Commercial |
$4,959.55
|
| Rate for Payer: WEA Trust Commercial |
$4,546.26
|
| Rate for Payer: WPS Commercial |
$6,122.34
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 36MM +7MM 00-8775-036-04
|
Facility
|
OP
|
$7,948.00
|
|
| Hospital Charge Code |
4230460
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,314.46 |
| Max. Negotiated Rate |
$7,604.65 |
| Rate for Payer: Aetna Commercial |
$7,439.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,108.69
|
| Rate for Payer: Aetna Managed Medicare |
$2,314.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,372.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,132.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,967.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,380.94
|
| Rate for Payer: Cash Price |
$2,384.40
|
| Rate for Payer: Cigna Commercial |
$7,604.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,625.74
|
| Rate for Payer: Health EOS Commercial |
$7,356.67
|
| Rate for Payer: HFN Commercial |
$7,604.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,199.44
|
| Rate for Payer: Multiplan Commercial |
$6,612.74
|
| Rate for Payer: NAPHCARE Commercial |
$4,959.55
|
| Rate for Payer: Preferred Network Access Commercial |
$7,604.65
|
| Rate for Payer: Quartz Beloit One Network |
$4,050.30
|
| Rate for Payer: Quartz Commercial |
$5,372.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,959.55
|
| Rate for Payer: The Alliance Commercial |
$4,132.96
|
| Rate for Payer: WEA Trust Commercial |
$4,546.26
|
| Rate for Payer: WPS Commercial |
$6,122.34
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC FOR TAPER SLEEVE 28MM 650-1055
|
Facility
|
OP
|
$8,184.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,383.18 |
| Max. Negotiated Rate |
$7,830.45 |
| Rate for Payer: Aetna Commercial |
$7,660.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,319.77
|
| Rate for Payer: Aetna Managed Medicare |
$2,383.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,532.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,255.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,085.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,511.02
|
| Rate for Payer: Cash Price |
$2,455.20
|
| Rate for Payer: Cigna Commercial |
$7,830.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,763.09
|
| Rate for Payer: Health EOS Commercial |
$7,575.11
|
| Rate for Payer: HFN Commercial |
$7,830.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,383.52
|
| Rate for Payer: Multiplan Commercial |
$6,809.09
|
| Rate for Payer: NAPHCARE Commercial |
$5,106.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,830.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,170.57
|
| Rate for Payer: Quartz Commercial |
$5,532.38
|
| Rate for Payer: Quartz Medicare Advantage |
$5,106.82
|
| Rate for Payer: The Alliance Commercial |
$4,255.68
|
| Rate for Payer: WEA Trust Commercial |
$4,681.25
|
| Rate for Payer: WPS Commercial |
$6,304.14
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC FOR TAPER SLEEVE 28MM 650-1055
|
Facility
|
IP
|
$8,184.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,170.57 |
| Max. Negotiated Rate |
$7,830.45 |
| Rate for Payer: Aetna Commercial |
$7,660.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,319.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,511.02
|
| Rate for Payer: Cash Price |
$2,455.20
|
| Rate for Payer: Cigna Commercial |
$7,830.45
|
| Rate for Payer: Health EOS Commercial |
$7,575.11
|
| Rate for Payer: HFN Commercial |
$7,830.45
|
| Rate for Payer: Multiplan Commercial |
$6,809.09
|
| Rate for Payer: Preferred Network Access Commercial |
$7,830.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,170.57
|
| Rate for Payer: Quartz Commercial |
$5,106.82
|
| Rate for Payer: WEA Trust Commercial |
$4,681.25
|
| Rate for Payer: WPS Commercial |
$6,304.14
|
|
|
FEMORAL HEAD BIOLOX DELTA MODULAR CERAMIC 36MM/-3MM STD 650-0660
|
Facility
|
IP
|
$4,859.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6179801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,476.15 |
| Max. Negotiated Rate |
$4,649.09 |
| Rate for Payer: Aetna Commercial |
$4,548.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,345.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.28
|
| Rate for Payer: Cash Price |
$1,457.70
|
| Rate for Payer: Cigna Commercial |
$4,649.09
|
| Rate for Payer: Health EOS Commercial |
$4,497.49
|
| Rate for Payer: HFN Commercial |
$4,649.09
|
| Rate for Payer: Multiplan Commercial |
$4,042.69
|
| Rate for Payer: Preferred Network Access Commercial |
$4,649.09
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.15
|
| Rate for Payer: Quartz Commercial |
$3,032.02
|
| Rate for Payer: WEA Trust Commercial |
$2,779.35
|
| Rate for Payer: WPS Commercial |
$3,742.89
|
|
|
FEMORAL HEAD BIOLOX DELTA MODULAR CERAMIC 36MM/-3MM STD 650-0660
|
Facility
|
OP
|
$4,859.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6179801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,414.94 |
| Max. Negotiated Rate |
$4,649.09 |
| Rate for Payer: Aetna Commercial |
$4,548.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,345.89
|
| Rate for Payer: Aetna Managed Medicare |
$1,414.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,284.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,526.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,425.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.28
|
| Rate for Payer: Cash Price |
$1,457.70
|
| Rate for Payer: Cigna Commercial |
$4,649.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,827.94
|
| Rate for Payer: Health EOS Commercial |
$4,497.49
|
| Rate for Payer: HFN Commercial |
$4,649.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,790.02
|
| Rate for Payer: Multiplan Commercial |
$4,042.69
|
| Rate for Payer: NAPHCARE Commercial |
$3,032.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,649.09
|
| Rate for Payer: Quartz Beloit One Network |
$2,476.15
|
| Rate for Payer: Quartz Commercial |
$3,284.68
|
| Rate for Payer: Quartz Medicare Advantage |
$3,032.02
|
| Rate for Payer: The Alliance Commercial |
$2,526.68
|
| Rate for Payer: WEA Trust Commercial |
$2,779.35
|
| Rate for Payer: WPS Commercial |
$3,742.89
|
|
|
FEMORAL HEAD BIOLOX DELTA MODULAR CERAMIC 36MM STD 12-115121
|
Facility
|
IP
|
$6,117.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563438
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,117.22 |
| Max. Negotiated Rate |
$5,852.75 |
| Rate for Payer: Aetna Commercial |
$5,725.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.69
|
| Rate for Payer: Cash Price |
$1,835.10
|
| Rate for Payer: Cigna Commercial |
$5,852.75
|
| Rate for Payer: Health EOS Commercial |
$5,661.90
|
| Rate for Payer: HFN Commercial |
$5,852.75
|
| Rate for Payer: Multiplan Commercial |
$5,089.34
|
| Rate for Payer: Preferred Network Access Commercial |
$5,852.75
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.22
|
| Rate for Payer: Quartz Commercial |
$3,817.01
|
| Rate for Payer: WEA Trust Commercial |
$3,498.92
|
| Rate for Payer: WPS Commercial |
$4,711.93
|
|
|
FEMORAL HEAD BIOLOX DELTA MODULAR CERAMIC 36MM STD 12-115121
|
Facility
|
OP
|
$6,117.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563438
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,781.27 |
| Max. Negotiated Rate |
$5,852.75 |
| Rate for Payer: Aetna Commercial |
$5,725.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,781.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,135.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,180.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,053.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.69
|
| Rate for Payer: Cash Price |
$1,835.10
|
| Rate for Payer: Cigna Commercial |
$5,852.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,560.09
|
| Rate for Payer: Health EOS Commercial |
$5,661.90
|
| Rate for Payer: HFN Commercial |
$5,852.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,771.26
|
| Rate for Payer: Multiplan Commercial |
$5,089.34
|
| Rate for Payer: NAPHCARE Commercial |
$3,817.01
|
| Rate for Payer: Preferred Network Access Commercial |
$5,852.75
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.22
|
| Rate for Payer: Quartz Commercial |
$4,135.09
|
| Rate for Payer: Quartz Medicare Advantage |
$3,817.01
|
| Rate for Payer: The Alliance Commercial |
$3,180.84
|
| Rate for Payer: WEA Trust Commercial |
$3,498.92
|
| Rate for Payer: WPS Commercial |
$4,711.93
|
|
|
FEMORAL HEAD BIOLOX DELTA MODULAR CERAMIC 36MM STD 650-0661
|
Facility
|
OP
|
$5,053.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6065702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.43 |
| Max. Negotiated Rate |
$4,834.71 |
| Rate for Payer: Aetna Commercial |
$4,729.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,519.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,471.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,415.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,627.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,522.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.21
|
| Rate for Payer: Cash Price |
$1,515.90
|
| Rate for Payer: Cigna Commercial |
$4,834.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,940.85
|
| Rate for Payer: Health EOS Commercial |
$4,677.06
|
| Rate for Payer: HFN Commercial |
$4,834.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,941.34
|
| Rate for Payer: Multiplan Commercial |
$4,204.10
|
| Rate for Payer: NAPHCARE Commercial |
$3,153.07
|
| Rate for Payer: Preferred Network Access Commercial |
$4,834.71
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.01
|
| Rate for Payer: Quartz Commercial |
$3,415.83
|
| Rate for Payer: Quartz Medicare Advantage |
$3,153.07
|
| Rate for Payer: The Alliance Commercial |
$2,627.56
|
| Rate for Payer: WEA Trust Commercial |
$2,890.32
|
| Rate for Payer: WPS Commercial |
$3,892.33
|
|
|
FEMORAL HEAD BIOLOX DELTA MODULAR CERAMIC 36MM STD 650-0661
|
Facility
|
IP
|
$5,053.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6065702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,575.01 |
| Max. Negotiated Rate |
$4,834.71 |
| Rate for Payer: Aetna Commercial |
$4,729.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,519.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.21
|
| Rate for Payer: Cash Price |
$1,515.90
|
| Rate for Payer: Cigna Commercial |
$4,834.71
|
| Rate for Payer: Health EOS Commercial |
$4,677.06
|
| Rate for Payer: HFN Commercial |
$4,834.71
|
| Rate for Payer: Multiplan Commercial |
$4,204.10
|
| Rate for Payer: Preferred Network Access Commercial |
$4,834.71
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.01
|
| Rate for Payer: Quartz Commercial |
$3,153.07
|
| Rate for Payer: WEA Trust Commercial |
$2,890.32
|
| Rate for Payer: WPS Commercial |
$3,892.33
|
|
|
FEMORAL HEAD CERAMIC 32MM -2.5 18-32-3
|
Facility
|
OP
|
$7,170.00
|
|
| Hospital Charge Code |
3072549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,087.90 |
| Max. Negotiated Rate |
$6,860.26 |
| Rate for Payer: Aetna Commercial |
$6,711.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,412.85
|
| Rate for Payer: Aetna Managed Medicare |
$2,087.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,846.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,728.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,579.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,952.10
|
| Rate for Payer: Cash Price |
$2,151.00
|
| Rate for Payer: Cigna Commercial |
$6,860.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,172.94
|
| Rate for Payer: Health EOS Commercial |
$6,636.55
|
| Rate for Payer: HFN Commercial |
$6,860.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,592.60
|
| Rate for Payer: Multiplan Commercial |
$5,965.44
|
| Rate for Payer: NAPHCARE Commercial |
$4,474.08
|
| Rate for Payer: Preferred Network Access Commercial |
$6,860.26
|
| Rate for Payer: Quartz Beloit One Network |
$3,653.83
|
| Rate for Payer: Quartz Commercial |
$4,846.92
|
| Rate for Payer: Quartz Medicare Advantage |
$4,474.08
|
| Rate for Payer: The Alliance Commercial |
$3,728.40
|
| Rate for Payer: WEA Trust Commercial |
$4,101.24
|
| Rate for Payer: WPS Commercial |
$5,523.05
|
|
|
FEMORAL HEAD CERAMIC 32MM -2.5 18-32-3
|
Facility
|
IP
|
$7,170.00
|
|
| Hospital Charge Code |
3072549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,653.83 |
| Max. Negotiated Rate |
$6,860.26 |
| Rate for Payer: Aetna Commercial |
$6,711.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,412.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,952.10
|
| Rate for Payer: Cash Price |
$2,151.00
|
| Rate for Payer: Cigna Commercial |
$6,860.26
|
| Rate for Payer: Health EOS Commercial |
$6,636.55
|
| Rate for Payer: HFN Commercial |
$6,860.26
|
| Rate for Payer: Multiplan Commercial |
$5,965.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,860.26
|
| Rate for Payer: Quartz Beloit One Network |
$3,653.83
|
| Rate for Payer: Quartz Commercial |
$4,474.08
|
| Rate for Payer: WEA Trust Commercial |
$4,101.24
|
| Rate for Payer: WPS Commercial |
$5,523.05
|
|
|
FEMORAL HEAD COCR 28MM +0 802202802
|
Facility
|
IP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5895652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.36 |
| Max. Negotiated Rate |
$4,022.39 |
| Rate for Payer: Aetna Commercial |
$3,934.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,760.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,317.24
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$4,022.39
|
| Rate for Payer: Health EOS Commercial |
$3,891.22
|
| Rate for Payer: HFN Commercial |
$4,022.39
|
| Rate for Payer: Multiplan Commercial |
$3,497.73
|
| Rate for Payer: Preferred Network Access Commercial |
$4,022.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,142.36
|
| Rate for Payer: Quartz Commercial |
$2,623.30
|
| Rate for Payer: WEA Trust Commercial |
$2,404.69
|
| Rate for Payer: WPS Commercial |
$3,238.34
|
|
|
FEMORAL HEAD COCR 28MM +0 802202802
|
Facility
|
OP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5895652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,224.20 |
| Max. Negotiated Rate |
$4,022.39 |
| Rate for Payer: Aetna Commercial |
$3,934.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,760.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,224.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,841.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,186.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,098.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,317.24
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$4,022.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,446.73
|
| Rate for Payer: Health EOS Commercial |
$3,891.22
|
| Rate for Payer: HFN Commercial |
$4,022.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,279.12
|
| Rate for Payer: Multiplan Commercial |
$3,497.73
|
| Rate for Payer: NAPHCARE Commercial |
$2,623.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,022.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,142.36
|
| Rate for Payer: Quartz Commercial |
$2,841.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,623.30
|
| Rate for Payer: The Alliance Commercial |
$2,186.08
|
| Rate for Payer: WEA Trust Commercial |
$2,404.69
|
| Rate for Payer: WPS Commercial |
$3,238.34
|
|
|
FEMORAL HEAD COCR 28MM -3.5 802202801
|
Facility
|
IP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.36 |
| Max. Negotiated Rate |
$4,022.39 |
| Rate for Payer: Aetna Commercial |
$3,934.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,760.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,317.24
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$4,022.39
|
| Rate for Payer: Health EOS Commercial |
$3,891.22
|
| Rate for Payer: HFN Commercial |
$4,022.39
|
| Rate for Payer: Multiplan Commercial |
$3,497.73
|
| Rate for Payer: Preferred Network Access Commercial |
$4,022.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,142.36
|
| Rate for Payer: Quartz Commercial |
$2,623.30
|
| Rate for Payer: WEA Trust Commercial |
$2,404.69
|
| Rate for Payer: WPS Commercial |
$3,238.34
|
|
|
FEMORAL HEAD COCR 28MM -3.5 802202801
|
Facility
|
OP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,224.20 |
| Max. Negotiated Rate |
$4,022.39 |
| Rate for Payer: Aetna Commercial |
$3,934.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,760.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,224.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,841.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,186.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,098.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,317.24
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$4,022.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,446.73
|
| Rate for Payer: Health EOS Commercial |
$3,891.22
|
| Rate for Payer: HFN Commercial |
$4,022.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,279.12
|
| Rate for Payer: Multiplan Commercial |
$3,497.73
|
| Rate for Payer: NAPHCARE Commercial |
$2,623.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,022.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,142.36
|
| Rate for Payer: Quartz Commercial |
$2,841.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,623.30
|
| Rate for Payer: The Alliance Commercial |
$2,186.08
|
| Rate for Payer: WEA Trust Commercial |
$2,404.69
|
| Rate for Payer: WPS Commercial |
$3,238.34
|
|
|
FEMORAL HEAD COCR 28MM +3.5 802202803
|
Facility
|
IP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5810137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.36 |
| Max. Negotiated Rate |
$4,022.39 |
| Rate for Payer: Aetna Commercial |
$3,934.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,760.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,317.24
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$4,022.39
|
| Rate for Payer: Health EOS Commercial |
$3,891.22
|
| Rate for Payer: HFN Commercial |
$4,022.39
|
| Rate for Payer: Multiplan Commercial |
$3,497.73
|
| Rate for Payer: Preferred Network Access Commercial |
$4,022.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,142.36
|
| Rate for Payer: Quartz Commercial |
$2,623.30
|
| Rate for Payer: WEA Trust Commercial |
$2,404.69
|
| Rate for Payer: WPS Commercial |
$3,238.34
|
|
|
FEMORAL HEAD COCR 28MM +3.5 802202803
|
Facility
|
OP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5810137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,224.20 |
| Max. Negotiated Rate |
$4,022.39 |
| Rate for Payer: Aetna Commercial |
$3,934.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,760.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,224.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,841.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,186.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,098.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,317.24
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$4,022.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,446.73
|
| Rate for Payer: Health EOS Commercial |
$3,891.22
|
| Rate for Payer: HFN Commercial |
$4,022.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,279.12
|
| Rate for Payer: Multiplan Commercial |
$3,497.73
|
| Rate for Payer: NAPHCARE Commercial |
$2,623.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,022.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,142.36
|
| Rate for Payer: Quartz Commercial |
$2,841.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,623.30
|
| Rate for Payer: The Alliance Commercial |
$2,186.08
|
| Rate for Payer: WEA Trust Commercial |
$2,404.69
|
| Rate for Payer: WPS Commercial |
$3,238.34
|
|
|
FEMORAL HEAD COCR 28MM +7.0 802202804
|
Facility
|
IP
|
$3,924.28
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,999.81 |
| Max. Negotiated Rate |
$3,754.75 |
| Rate for Payer: Aetna Commercial |
$3,673.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,509.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,163.06
|
| Rate for Payer: Cash Price |
$1,177.28
|
| Rate for Payer: Cigna Commercial |
$3,754.75
|
| Rate for Payer: Health EOS Commercial |
$3,632.31
|
| Rate for Payer: HFN Commercial |
$3,754.75
|
| Rate for Payer: Multiplan Commercial |
$3,265.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,754.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,999.81
|
| Rate for Payer: Quartz Commercial |
$2,448.75
|
| Rate for Payer: WEA Trust Commercial |
$2,244.69
|
| Rate for Payer: WPS Commercial |
$3,022.87
|
|
|
FEMORAL HEAD COCR 28MM +7.0 802202804
|
Facility
|
OP
|
$3,924.28
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.75 |
| Max. Negotiated Rate |
$3,754.75 |
| Rate for Payer: Aetna Commercial |
$3,673.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,509.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,142.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,652.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,040.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,959.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,163.06
|
| Rate for Payer: Cash Price |
$1,177.28
|
| Rate for Payer: Cigna Commercial |
$3,754.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,283.93
|
| Rate for Payer: Health EOS Commercial |
$3,632.31
|
| Rate for Payer: HFN Commercial |
$3,754.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,060.94
|
| Rate for Payer: Multiplan Commercial |
$3,265.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,448.75
|
| Rate for Payer: Preferred Network Access Commercial |
$3,754.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,999.81
|
| Rate for Payer: Quartz Commercial |
$2,652.81
|
| Rate for Payer: Quartz Medicare Advantage |
$2,448.75
|
| Rate for Payer: The Alliance Commercial |
$2,040.63
|
| Rate for Payer: WEA Trust Commercial |
$2,244.69
|
| Rate for Payer: WPS Commercial |
$3,022.87
|
|
|
FEMORAL HEAD LFIT 36MM +2.5MM
|
Facility
|
IP
|
$5,492.00
|
|
| Hospital Charge Code |
3072476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,798.72 |
| Max. Negotiated Rate |
$5,254.75 |
| Rate for Payer: Aetna Commercial |
$5,140.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,912.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,027.19
|
| Rate for Payer: Cash Price |
$1,647.60
|
| Rate for Payer: Cigna Commercial |
$5,254.75
|
| Rate for Payer: Health EOS Commercial |
$5,083.40
|
| Rate for Payer: HFN Commercial |
$5,254.75
|
| Rate for Payer: Multiplan Commercial |
$4,569.34
|
| Rate for Payer: Preferred Network Access Commercial |
$5,254.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,798.72
|
| Rate for Payer: Quartz Commercial |
$3,427.01
|
| Rate for Payer: WEA Trust Commercial |
$3,141.42
|
| Rate for Payer: WPS Commercial |
$4,230.49
|
|
|
FEMORAL HEAD LFIT 36MM +2.5MM
|
Facility
|
OP
|
$5,492.00
|
|
| Hospital Charge Code |
3072476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,599.27 |
| Max. Negotiated Rate |
$5,254.75 |
| Rate for Payer: Aetna Commercial |
$5,140.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,912.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,599.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,712.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,855.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,741.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,027.19
|
| Rate for Payer: Cash Price |
$1,647.60
|
| Rate for Payer: Cigna Commercial |
$5,254.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,196.34
|
| Rate for Payer: Health EOS Commercial |
$5,083.40
|
| Rate for Payer: HFN Commercial |
$5,254.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,283.76
|
| Rate for Payer: Multiplan Commercial |
$4,569.34
|
| Rate for Payer: NAPHCARE Commercial |
$3,427.01
|
| Rate for Payer: Preferred Network Access Commercial |
$5,254.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,798.72
|
| Rate for Payer: Quartz Commercial |
$3,712.59
|
| Rate for Payer: Quartz Medicare Advantage |
$3,427.01
|
| Rate for Payer: The Alliance Commercial |
$2,855.84
|
| Rate for Payer: WEA Trust Commercial |
$3,141.42
|
| Rate for Payer: WPS Commercial |
$4,230.49
|
|
|
FEMORAL HEAD LFIT 36MM 3.5 OFFSET 06-3605
|
Facility
|
IP
|
$11,045.00
|
|
| Hospital Charge Code |
2966086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,628.53 |
| Max. Negotiated Rate |
$10,567.86 |
| Rate for Payer: Aetna Commercial |
$10,338.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,878.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,088.00
|
| Rate for Payer: Cash Price |
$3,313.50
|
| Rate for Payer: Cigna Commercial |
$10,567.86
|
| Rate for Payer: Health EOS Commercial |
$10,223.25
|
| Rate for Payer: HFN Commercial |
$10,567.86
|
| Rate for Payer: Multiplan Commercial |
$9,189.44
|
| Rate for Payer: Preferred Network Access Commercial |
$10,567.86
|
| Rate for Payer: Quartz Beloit One Network |
$5,628.53
|
| Rate for Payer: Quartz Commercial |
$6,892.08
|
| Rate for Payer: WEA Trust Commercial |
$6,317.74
|
| Rate for Payer: WPS Commercial |
$8,507.96
|
|
|
FEMORAL HEAD LFIT 36MM 3.5 OFFSET 06-3605
|
Facility
|
OP
|
$11,045.00
|
|
| Hospital Charge Code |
2966086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,216.30 |
| Max. Negotiated Rate |
$10,567.86 |
| Rate for Payer: Aetna Commercial |
$10,338.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,878.65
|
| Rate for Payer: Aetna Managed Medicare |
$3,216.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,466.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,743.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,513.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,088.00
|
| Rate for Payer: Cash Price |
$3,313.50
|
| Rate for Payer: Cigna Commercial |
$10,567.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,428.19
|
| Rate for Payer: Health EOS Commercial |
$10,223.25
|
| Rate for Payer: HFN Commercial |
$10,567.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,615.10
|
| Rate for Payer: Multiplan Commercial |
$9,189.44
|
| Rate for Payer: NAPHCARE Commercial |
$6,892.08
|
| Rate for Payer: Preferred Network Access Commercial |
$10,567.86
|
| Rate for Payer: Quartz Beloit One Network |
$5,628.53
|
| Rate for Payer: Quartz Commercial |
$7,466.42
|
| Rate for Payer: Quartz Medicare Advantage |
$6,892.08
|
| Rate for Payer: The Alliance Commercial |
$5,743.40
|
| Rate for Payer: WEA Trust Commercial |
$6,317.74
|
| Rate for Payer: WPS Commercial |
$8,507.96
|
|
|
FEMORAL HEAD LFIT V40 36MM +0 6260-9-136
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4520308
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
