|
FEMORAL HEAD M-SPEC METAL 36MM +5 12/14 1365-52-000
|
Facility
|
IP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,536.79 |
| Max. Negotiated Rate |
$4,762.95 |
| Rate for Payer: Aetna Commercial |
$4,659.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,452.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,743.87
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,762.95
|
| Rate for Payer: Health EOS Commercial |
$4,607.64
|
| Rate for Payer: HFN Commercial |
$4,762.95
|
| Rate for Payer: Multiplan Commercial |
$4,141.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,536.79
|
| Rate for Payer: Quartz Commercial |
$3,106.27
|
| Rate for Payer: WEA Trust Commercial |
$2,847.42
|
| Rate for Payer: WPS Commercial |
$3,834.55
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +5 12/14 1365-52-000
|
Facility
|
OP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.59 |
| Max. Negotiated Rate |
$4,762.95 |
| Rate for Payer: Aetna Commercial |
$4,659.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,452.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,449.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,365.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,588.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,485.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,743.87
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,762.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,897.20
|
| Rate for Payer: Health EOS Commercial |
$4,607.64
|
| Rate for Payer: HFN Commercial |
$4,762.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,882.84
|
| Rate for Payer: Multiplan Commercial |
$4,141.70
|
| Rate for Payer: NAPHCARE Commercial |
$3,106.27
|
| Rate for Payer: Preferred Network Access Commercial |
$4,762.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,536.79
|
| Rate for Payer: Quartz Commercial |
$3,365.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,106.27
|
| Rate for Payer: The Alliance Commercial |
$2,588.56
|
| Rate for Payer: WEA Trust Commercial |
$2,847.42
|
| Rate for Payer: WPS Commercial |
$3,834.55
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +8.5 12/14 1365-53-000
|
Facility
|
IP
|
$4,787.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563409
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.46 |
| Max. Negotiated Rate |
$4,580.20 |
| Rate for Payer: Aetna Commercial |
$4,480.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.59
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,580.20
|
| Rate for Payer: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.46
|
| Rate for Payer: Quartz Commercial |
$2,987.09
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +8.5 12/14 1365-53-000
|
Facility
|
OP
|
$4,787.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563409
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.97 |
| Max. Negotiated Rate |
$4,580.20 |
| Rate for Payer: Aetna Commercial |
$4,480.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.49
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,236.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.59
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,580.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,786.03
|
| Rate for Payer: Health EOS Commercial |
$4,430.85
|
| Rate for Payer: HFN Commercial |
$4,580.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.86
|
| Rate for Payer: Multiplan Commercial |
$3,982.78
|
| Rate for Payer: NAPHCARE Commercial |
$2,987.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.46
|
| Rate for Payer: Quartz Commercial |
$3,236.01
|
| Rate for Payer: Quartz Medicare Advantage |
$2,987.09
|
| Rate for Payer: The Alliance Commercial |
$2,489.24
|
| Rate for Payer: WEA Trust Commercial |
$2,738.16
|
| Rate for Payer: WPS Commercial |
$3,687.43
|
|
|
FEMORAL HEAD M-SPEC METAL 40MM +12 12/14 1365-08-000
|
Facility
|
IP
|
$5,578.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6198967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,842.55 |
| Max. Negotiated Rate |
$5,337.03 |
| Rate for Payer: Aetna Commercial |
$5,221.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,988.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,074.59
|
| Rate for Payer: Cash Price |
$1,673.40
|
| Rate for Payer: Cigna Commercial |
$5,337.03
|
| Rate for Payer: Health EOS Commercial |
$5,163.00
|
| Rate for Payer: HFN Commercial |
$5,337.03
|
| Rate for Payer: Multiplan Commercial |
$4,640.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,337.03
|
| Rate for Payer: Quartz Beloit One Network |
$2,842.55
|
| Rate for Payer: Quartz Commercial |
$3,480.67
|
| Rate for Payer: WEA Trust Commercial |
$3,190.62
|
| Rate for Payer: WPS Commercial |
$4,296.73
|
|
|
FEMORAL HEAD M-SPEC METAL 40MM +12 12/14 1365-08-000
|
Facility
|
OP
|
$5,578.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6198967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,624.31 |
| Max. Negotiated Rate |
$5,337.03 |
| Rate for Payer: Aetna Commercial |
$5,221.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,988.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,624.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,770.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,900.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,784.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,074.59
|
| Rate for Payer: Cash Price |
$1,673.40
|
| Rate for Payer: Cigna Commercial |
$5,337.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,246.40
|
| Rate for Payer: Health EOS Commercial |
$5,163.00
|
| Rate for Payer: HFN Commercial |
$5,337.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,350.84
|
| Rate for Payer: Multiplan Commercial |
$4,640.90
|
| Rate for Payer: NAPHCARE Commercial |
$3,480.67
|
| Rate for Payer: Preferred Network Access Commercial |
$5,337.03
|
| Rate for Payer: Quartz Beloit One Network |
$2,842.55
|
| Rate for Payer: Quartz Commercial |
$3,770.73
|
| Rate for Payer: Quartz Medicare Advantage |
$3,480.67
|
| Rate for Payer: The Alliance Commercial |
$2,900.56
|
| Rate for Payer: WEA Trust Commercial |
$3,190.62
|
| Rate for Payer: WPS Commercial |
$4,296.73
|
|
|
FEMORAL HEAD VERSYS 28MM +0 8018-28-02
|
Facility
|
OP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.37 |
| Max. Negotiated Rate |
$4,624.21 |
| Rate for Payer: Aetna Commercial |
$4,523.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,407.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,267.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,513.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,412.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.95
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,624.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,812.81
|
| Rate for Payer: Health EOS Commercial |
$4,473.42
|
| Rate for Payer: HFN Commercial |
$4,624.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,769.74
|
| Rate for Payer: Multiplan Commercial |
$4,021.06
|
| Rate for Payer: NAPHCARE Commercial |
$3,015.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,624.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.90
|
| Rate for Payer: Quartz Commercial |
$3,267.11
|
| Rate for Payer: Quartz Medicare Advantage |
$3,015.79
|
| Rate for Payer: The Alliance Commercial |
$2,513.16
|
| Rate for Payer: WEA Trust Commercial |
$2,764.48
|
| Rate for Payer: WPS Commercial |
$3,722.86
|
|
|
FEMORAL HEAD VERSYS 28MM +0 8018-28-02
|
Facility
|
IP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,462.90 |
| Max. Negotiated Rate |
$4,624.21 |
| Rate for Payer: Aetna Commercial |
$4,523.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.95
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,624.21
|
| Rate for Payer: Health EOS Commercial |
$4,473.42
|
| Rate for Payer: HFN Commercial |
$4,624.21
|
| Rate for Payer: Multiplan Commercial |
$4,021.06
|
| Rate for Payer: Preferred Network Access Commercial |
$4,624.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.90
|
| Rate for Payer: Quartz Commercial |
$3,015.79
|
| Rate for Payer: WEA Trust Commercial |
$2,764.48
|
| Rate for Payer: WPS Commercial |
$3,722.86
|
|
|
FEMORAL HEAD VERSYS 28MM +10.5 8018-28-05
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967873
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD VERSYS 28MM +10.5 8018-28-05
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967873
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD VERSYS 28MM -3.5 8018-28-01
|
Facility
|
IP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3138916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,462.90 |
| Max. Negotiated Rate |
$4,624.21 |
| Rate for Payer: Aetna Commercial |
$4,523.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.95
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,624.21
|
| Rate for Payer: Health EOS Commercial |
$4,473.42
|
| Rate for Payer: HFN Commercial |
$4,624.21
|
| Rate for Payer: Multiplan Commercial |
$4,021.06
|
| Rate for Payer: Preferred Network Access Commercial |
$4,624.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.90
|
| Rate for Payer: Quartz Commercial |
$3,015.79
|
| Rate for Payer: WEA Trust Commercial |
$2,764.48
|
| Rate for Payer: WPS Commercial |
$3,722.86
|
|
|
FEMORAL HEAD VERSYS 28MM -3.5 8018-28-01
|
Facility
|
OP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3138916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.37 |
| Max. Negotiated Rate |
$4,624.21 |
| Rate for Payer: Aetna Commercial |
$4,523.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,322.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,407.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,267.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,513.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,412.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,663.95
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,624.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,812.81
|
| Rate for Payer: Health EOS Commercial |
$4,473.42
|
| Rate for Payer: HFN Commercial |
$4,624.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,769.74
|
| Rate for Payer: Multiplan Commercial |
$4,021.06
|
| Rate for Payer: NAPHCARE Commercial |
$3,015.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,624.21
|
| Rate for Payer: Quartz Beloit One Network |
$2,462.90
|
| Rate for Payer: Quartz Commercial |
$3,267.11
|
| Rate for Payer: Quartz Medicare Advantage |
$3,015.79
|
| Rate for Payer: The Alliance Commercial |
$2,513.16
|
| Rate for Payer: WEA Trust Commercial |
$2,764.48
|
| Rate for Payer: WPS Commercial |
$3,722.86
|
|
|
FEMORAL HEAD VERSYS 28MM +3.5 8018-28-03
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD VERSYS 28MM +3.5 8018-28-03
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD VERSYS 28MM +7.0 8018-28-04
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.17 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$2,903.47
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD VERSYS 28MM +7.0 8018-28-04
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.95 |
| Max. Negotiated Rate |
$4,451.99 |
| Rate for Payer: Aetna Commercial |
$4,355.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,161.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,354.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,145.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,419.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,322.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,564.73
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,451.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,708.05
|
| Rate for Payer: Health EOS Commercial |
$4,306.82
|
| Rate for Payer: HFN Commercial |
$4,451.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,629.34
|
| Rate for Payer: Multiplan Commercial |
$3,871.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,903.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,451.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,371.17
|
| Rate for Payer: Quartz Commercial |
$3,145.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,903.47
|
| Rate for Payer: The Alliance Commercial |
$2,419.56
|
| Rate for Payer: WEA Trust Commercial |
$2,661.52
|
| Rate for Payer: WPS Commercial |
$3,584.21
|
|
|
FEMORAL HEAD VERSYS 36MM +0 8018-36-02
|
Facility
|
OP
|
$9,076.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,642.93 |
| Max. Negotiated Rate |
$8,683.92 |
| Rate for Payer: Aetna Commercial |
$8,495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,117.57
|
| Rate for Payer: Aetna Managed Medicare |
$2,642.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,135.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,719.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,530.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,002.69
|
| Rate for Payer: Cash Price |
$2,722.80
|
| Rate for Payer: Cigna Commercial |
$8,683.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,282.23
|
| Rate for Payer: Health EOS Commercial |
$8,400.75
|
| Rate for Payer: HFN Commercial |
$8,683.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,079.28
|
| Rate for Payer: Multiplan Commercial |
$7,551.23
|
| Rate for Payer: NAPHCARE Commercial |
$5,663.42
|
| Rate for Payer: Preferred Network Access Commercial |
$8,683.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,625.13
|
| Rate for Payer: Quartz Commercial |
$6,135.38
|
| Rate for Payer: Quartz Medicare Advantage |
$5,663.42
|
| Rate for Payer: The Alliance Commercial |
$4,719.52
|
| Rate for Payer: WEA Trust Commercial |
$5,191.47
|
| Rate for Payer: WPS Commercial |
$6,991.24
|
|
|
FEMORAL HEAD VERSYS 36MM +0 8018-36-02
|
Facility
|
IP
|
$9,076.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,625.13 |
| Max. Negotiated Rate |
$8,683.92 |
| Rate for Payer: Aetna Commercial |
$8,495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,117.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,002.69
|
| Rate for Payer: Cash Price |
$2,722.80
|
| Rate for Payer: Cigna Commercial |
$8,683.92
|
| Rate for Payer: Health EOS Commercial |
$8,400.75
|
| Rate for Payer: HFN Commercial |
$8,683.92
|
| Rate for Payer: Multiplan Commercial |
$7,551.23
|
| Rate for Payer: Preferred Network Access Commercial |
$8,683.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,625.13
|
| Rate for Payer: Quartz Commercial |
$5,663.42
|
| Rate for Payer: WEA Trust Commercial |
$5,191.47
|
| Rate for Payer: WPS Commercial |
$6,991.24
|
|
|
FEMORAL HEAD VERSYS 36mm +10.5 8018-36-05
|
Facility
|
OP
|
$8,739.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,544.80 |
| Max. Negotiated Rate |
$8,361.48 |
| Rate for Payer: Aetna Commercial |
$8,179.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,816.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,544.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,907.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,544.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,362.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,816.94
|
| Rate for Payer: Cash Price |
$2,621.70
|
| Rate for Payer: Cigna Commercial |
$8,361.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,086.10
|
| Rate for Payer: Health EOS Commercial |
$8,088.82
|
| Rate for Payer: HFN Commercial |
$8,361.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,816.42
|
| Rate for Payer: Multiplan Commercial |
$7,270.85
|
| Rate for Payer: NAPHCARE Commercial |
$5,453.14
|
| Rate for Payer: Preferred Network Access Commercial |
$8,361.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.39
|
| Rate for Payer: Quartz Commercial |
$5,907.56
|
| Rate for Payer: Quartz Medicare Advantage |
$5,453.14
|
| Rate for Payer: The Alliance Commercial |
$4,544.28
|
| Rate for Payer: WEA Trust Commercial |
$4,998.71
|
| Rate for Payer: WPS Commercial |
$6,731.65
|
|
|
FEMORAL HEAD VERSYS 36mm +10.5 8018-36-05
|
Facility
|
IP
|
$8,739.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,453.39 |
| Max. Negotiated Rate |
$8,361.48 |
| Rate for Payer: Aetna Commercial |
$8,179.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,816.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,816.94
|
| Rate for Payer: Cash Price |
$2,621.70
|
| Rate for Payer: Cigna Commercial |
$8,361.48
|
| Rate for Payer: Health EOS Commercial |
$8,088.82
|
| Rate for Payer: HFN Commercial |
$8,361.48
|
| Rate for Payer: Multiplan Commercial |
$7,270.85
|
| Rate for Payer: Preferred Network Access Commercial |
$8,361.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.39
|
| Rate for Payer: Quartz Commercial |
$5,453.14
|
| Rate for Payer: WEA Trust Commercial |
$4,998.71
|
| Rate for Payer: WPS Commercial |
$6,731.65
|
|
|
FEMORAL HEAD VERSYS 36mm +3.5 8018-36-03
|
Facility
|
OP
|
$9,076.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,642.93 |
| Max. Negotiated Rate |
$8,683.92 |
| Rate for Payer: Aetna Commercial |
$8,495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,117.57
|
| Rate for Payer: Aetna Managed Medicare |
$2,642.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,135.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,719.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,530.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,002.69
|
| Rate for Payer: Cash Price |
$2,722.80
|
| Rate for Payer: Cigna Commercial |
$8,683.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,282.23
|
| Rate for Payer: Health EOS Commercial |
$8,400.75
|
| Rate for Payer: HFN Commercial |
$8,683.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,079.28
|
| Rate for Payer: Multiplan Commercial |
$7,551.23
|
| Rate for Payer: NAPHCARE Commercial |
$5,663.42
|
| Rate for Payer: Preferred Network Access Commercial |
$8,683.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,625.13
|
| Rate for Payer: Quartz Commercial |
$6,135.38
|
| Rate for Payer: Quartz Medicare Advantage |
$5,663.42
|
| Rate for Payer: The Alliance Commercial |
$4,719.52
|
| Rate for Payer: WEA Trust Commercial |
$5,191.47
|
| Rate for Payer: WPS Commercial |
$6,991.24
|
|
|
FEMORAL HEAD VERSYS 36mm +3.5 8018-36-03
|
Facility
|
IP
|
$9,076.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,625.13 |
| Max. Negotiated Rate |
$8,683.92 |
| Rate for Payer: Aetna Commercial |
$8,495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,117.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,002.69
|
| Rate for Payer: Cash Price |
$2,722.80
|
| Rate for Payer: Cigna Commercial |
$8,683.92
|
| Rate for Payer: Health EOS Commercial |
$8,400.75
|
| Rate for Payer: HFN Commercial |
$8,683.92
|
| Rate for Payer: Multiplan Commercial |
$7,551.23
|
| Rate for Payer: Preferred Network Access Commercial |
$8,683.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,625.13
|
| Rate for Payer: Quartz Commercial |
$5,663.42
|
| Rate for Payer: WEA Trust Commercial |
$5,191.47
|
| Rate for Payer: WPS Commercial |
$6,991.24
|
|
|
FEMORAL HEAD VERSYS 36MM +7 8018-36-04
|
Facility
|
IP
|
$8,739.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,453.39 |
| Max. Negotiated Rate |
$8,361.48 |
| Rate for Payer: Aetna Commercial |
$8,179.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,816.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,816.94
|
| Rate for Payer: Cash Price |
$2,621.70
|
| Rate for Payer: Cigna Commercial |
$8,361.48
|
| Rate for Payer: Health EOS Commercial |
$8,088.82
|
| Rate for Payer: HFN Commercial |
$8,361.48
|
| Rate for Payer: Multiplan Commercial |
$7,270.85
|
| Rate for Payer: Preferred Network Access Commercial |
$8,361.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.39
|
| Rate for Payer: Quartz Commercial |
$5,453.14
|
| Rate for Payer: WEA Trust Commercial |
$4,998.71
|
| Rate for Payer: WPS Commercial |
$6,731.65
|
|
|
FEMORAL HEAD VERSYS 36MM +7 8018-36-04
|
Facility
|
OP
|
$8,739.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,544.80 |
| Max. Negotiated Rate |
$8,361.48 |
| Rate for Payer: Aetna Commercial |
$8,179.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,816.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,544.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,907.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,544.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,362.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,816.94
|
| Rate for Payer: Cash Price |
$2,621.70
|
| Rate for Payer: Cigna Commercial |
$8,361.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,086.10
|
| Rate for Payer: Health EOS Commercial |
$8,088.82
|
| Rate for Payer: HFN Commercial |
$8,361.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,816.42
|
| Rate for Payer: Multiplan Commercial |
$7,270.85
|
| Rate for Payer: NAPHCARE Commercial |
$5,453.14
|
| Rate for Payer: Preferred Network Access Commercial |
$8,361.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.39
|
| Rate for Payer: Quartz Commercial |
$5,907.56
|
| Rate for Payer: Quartz Medicare Advantage |
$5,453.14
|
| Rate for Payer: The Alliance Commercial |
$4,544.28
|
| Rate for Payer: WEA Trust Commercial |
$4,998.71
|
| Rate for Payer: WPS Commercial |
$6,731.65
|
|
|
FEMORAL HEAD VERSYS 40MM +7.0 8018-40-04
|
Facility
|
OP
|
$4,642.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5184691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,351.75 |
| Max. Negotiated Rate |
$4,441.47 |
| Rate for Payer: Aetna Commercial |
$4,344.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,151.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,351.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,137.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,413.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,317.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,558.67
|
| Rate for Payer: Cash Price |
$1,392.60
|
| Rate for Payer: Cigna Commercial |
$4,441.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,701.64
|
| Rate for Payer: Health EOS Commercial |
$4,296.64
|
| Rate for Payer: HFN Commercial |
$4,441.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,620.76
|
| Rate for Payer: Multiplan Commercial |
$3,862.14
|
| Rate for Payer: NAPHCARE Commercial |
$2,896.61
|
| Rate for Payer: Preferred Network Access Commercial |
$4,441.47
|
| Rate for Payer: Quartz Beloit One Network |
$2,365.56
|
| Rate for Payer: Quartz Commercial |
$3,137.99
|
| Rate for Payer: Quartz Medicare Advantage |
$2,896.61
|
| Rate for Payer: The Alliance Commercial |
$2,413.84
|
| Rate for Payer: WEA Trust Commercial |
$2,655.22
|
| Rate for Payer: WPS Commercial |
$3,575.73
|
|
