|
FEMORAL HEAD LFIT V40 36MM +0 6260-9-136
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4520308
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 36MM +10 6260-9-336
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
3487504
|
|
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
|
|
|
FEMORAL HEAD LFIT V40 36MM +10 6260-9-336
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
3487504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 36MM +5 6260-9-236
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4167700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 36MM +5 6260-9-236
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4167700
|
|
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
|
|
|
FEMORAL HEAD LFIT V40 40MM +0 6260-9-140
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4520142
|
|
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
|
|
|
FEMORAL HEAD LFIT V40 40MM +0 6260-9-140
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4520142
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 40MM +12 6260-9-440
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4520024
|
|
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
|
|
|
FEMORAL HEAD LFIT V40 40MM +12 6260-9-440
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4520024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 40MM +4 6260-9-240
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4028636
|
|
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
|
|
|
FEMORAL HEAD LFIT V40 40MM +4 6260-9-240
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4028636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 40MM +8 6260-9-340
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
3949331
|
|
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
|
|
|
FEMORAL HEAD LFIT V40 40MM +8 6260-9-340
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
3949331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 44MM -4 6260-9-044
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4508748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 44MM -4 6260-9-044
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4508748
|
|
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
|
|
|
FEMORAL HEAD LFIT V40 44MM +4 6260-9-244
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4594901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| 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: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| 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: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| 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 |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
FEMORAL HEAD LFIT V40 44MM +4 6260-9-244
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4594901
|
|
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
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +12 12/14 1365-54-000
|
Facility
|
OP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5597547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,213.72 |
| Max. Negotiated Rate |
$3,987.94 |
| Rate for Payer: Aetna Commercial |
$3,901.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,727.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,213.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,817.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,167.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,080.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,297.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,987.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,425.78
|
| Rate for Payer: Health EOS Commercial |
$3,857.90
|
| Rate for Payer: HFN Commercial |
$3,987.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,251.04
|
| Rate for Payer: Multiplan Commercial |
$3,467.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,600.83
|
| Rate for Payer: Preferred Network Access Commercial |
$3,987.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.01
|
| Rate for Payer: Quartz Commercial |
$2,817.57
|
| Rate for Payer: Quartz Medicare Advantage |
$2,600.83
|
| Rate for Payer: The Alliance Commercial |
$2,167.36
|
| Rate for Payer: WEA Trust Commercial |
$2,384.10
|
| Rate for Payer: WPS Commercial |
$3,210.61
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +12 12/14 1365-54-000
|
Facility
|
IP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5597547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,124.01 |
| Max. Negotiated Rate |
$3,987.94 |
| Rate for Payer: Aetna Commercial |
$3,901.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,727.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,297.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,987.94
|
| Rate for Payer: Health EOS Commercial |
$3,857.90
|
| Rate for Payer: HFN Commercial |
$3,987.94
|
| Rate for Payer: Multiplan Commercial |
$3,467.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,987.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.01
|
| Rate for Payer: Quartz Commercial |
$2,600.83
|
| Rate for Payer: WEA Trust Commercial |
$2,384.10
|
| Rate for Payer: WPS Commercial |
$3,210.61
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +1.5 12/14 1365-51-000
|
Facility
|
IP
|
$5,170.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496712
|
|
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 M-SPEC METAL 36MM +1.5 12/14 1365-51-000
|
Facility
|
OP
|
$5,170.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496712
|
|
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 M-SPEC METAL 36MM +15.5 12/14 1365-55-000
|
Facility
|
IP
|
$3,706.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6196976
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,888.58 |
| Max. Negotiated Rate |
$3,545.90 |
| Rate for Payer: Aetna Commercial |
$3,468.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,314.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,042.75
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cigna Commercial |
$3,545.90
|
| Rate for Payer: Health EOS Commercial |
$3,430.27
|
| Rate for Payer: HFN Commercial |
$3,545.90
|
| Rate for Payer: Multiplan Commercial |
$3,083.39
|
| Rate for Payer: Preferred Network Access Commercial |
$3,545.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,888.58
|
| Rate for Payer: Quartz Commercial |
$2,312.54
|
| Rate for Payer: WEA Trust Commercial |
$2,119.83
|
| Rate for Payer: WPS Commercial |
$2,854.73
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +15.5 12/14 1365-55-000
|
Facility
|
OP
|
$3,706.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6196976
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,079.19 |
| Max. Negotiated Rate |
$3,545.90 |
| Rate for Payer: Aetna Commercial |
$3,468.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,314.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,079.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,505.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,927.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,850.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,042.75
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cigna Commercial |
$3,545.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,156.89
|
| Rate for Payer: Health EOS Commercial |
$3,430.27
|
| Rate for Payer: HFN Commercial |
$3,545.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,890.68
|
| Rate for Payer: Multiplan Commercial |
$3,083.39
|
| Rate for Payer: NAPHCARE Commercial |
$2,312.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,545.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,888.58
|
| Rate for Payer: Quartz Commercial |
$2,505.26
|
| Rate for Payer: Quartz Medicare Advantage |
$2,312.54
|
| Rate for Payer: The Alliance Commercial |
$1,927.12
|
| Rate for Payer: WEA Trust Commercial |
$2,119.83
|
| Rate for Payer: WPS Commercial |
$2,854.73
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM -2 12/14 1365-50-000
|
Facility
|
IP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,124.01 |
| Max. Negotiated Rate |
$3,987.94 |
| Rate for Payer: Aetna Commercial |
$3,901.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,727.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,297.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,987.94
|
| Rate for Payer: Health EOS Commercial |
$3,857.90
|
| Rate for Payer: HFN Commercial |
$3,987.94
|
| Rate for Payer: Multiplan Commercial |
$3,467.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,987.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.01
|
| Rate for Payer: Quartz Commercial |
$2,600.83
|
| Rate for Payer: WEA Trust Commercial |
$2,384.10
|
| Rate for Payer: WPS Commercial |
$3,210.61
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM -2 12/14 1365-50-000
|
Facility
|
OP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,213.72 |
| Max. Negotiated Rate |
$3,987.94 |
| Rate for Payer: Aetna Commercial |
$3,901.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,727.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,213.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,817.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,167.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,080.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,297.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,987.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,425.78
|
| Rate for Payer: Health EOS Commercial |
$3,857.90
|
| Rate for Payer: HFN Commercial |
$3,987.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,251.04
|
| Rate for Payer: Multiplan Commercial |
$3,467.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,600.83
|
| Rate for Payer: Preferred Network Access Commercial |
$3,987.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.01
|
| Rate for Payer: Quartz Commercial |
$2,817.57
|
| Rate for Payer: Quartz Medicare Advantage |
$2,600.83
|
| Rate for Payer: The Alliance Commercial |
$2,167.36
|
| Rate for Payer: WEA Trust Commercial |
$2,384.10
|
| Rate for Payer: WPS Commercial |
$3,210.61
|
|
