|
FEMORAL COMPONENT SZ F RT LCCK 5994-16-92
|
Facility
|
IP
|
$31,995.00
|
|
| Hospital Charge Code |
2974029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,677.55 |
| Max. Negotiated Rate |
$29,435.40 |
| Rate for Payer: Aetna Commercial |
$28,795.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,515.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,957.35
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$29,435.40
|
| Rate for Payer: Health EOS Commercial |
$28,475.55
|
| Rate for Payer: HFN Commercial |
$29,435.40
|
| Rate for Payer: Multiplan Commercial |
$25,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,197.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,435.40
|
| Rate for Payer: Quartz Beloit One Network |
$15,677.55
|
| Rate for Payer: Quartz Commercial |
$19,197.00
|
| Rate for Payer: WEA Trust Commercial |
$17,597.25
|
| Rate for Payer: WPS Commercial |
$23,698.70
|
|
|
FEMORAL COMPONENT SZ F RT LCCK 5994-16-92
|
Facility
|
OP
|
$31,995.00
|
|
| Hospital Charge Code |
2974029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,958.60 |
| Max. Negotiated Rate |
$127,980.00 |
| Rate for Payer: Aetna Commercial |
$28,795.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,515.70
|
| Rate for Payer: Aetna Managed Medicare |
$8,958.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,796.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,997.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,357.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,957.35
|
| Rate for Payer: Cash Price |
$9,598.50
|
| Rate for Payer: Cigna Commercial |
$29,435.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,904.40
|
| Rate for Payer: Health EOS Commercial |
$28,475.55
|
| Rate for Payer: HFN Commercial |
$29,435.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,996.25
|
| Rate for Payer: Multiplan Commercial |
$25,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,197.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,435.40
|
| Rate for Payer: Quartz Beloit One Network |
$15,677.55
|
| Rate for Payer: Quartz Commercial |
$20,796.75
|
| Rate for Payer: Quartz Medicare Advantage |
$19,197.00
|
| Rate for Payer: The Alliance Commercial |
$127,980.00
|
| Rate for Payer: WEA Trust Commercial |
$17,597.25
|
| Rate for Payer: WPS Commercial |
$23,698.70
|
|
|
FEMORAL COMPONENT TRIATHLON TS SZ 4 RT 5512-F-402
|
Facility
|
IP
|
$27,557.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246163
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,503.11 |
| Max. Negotiated Rate |
$25,352.78 |
| Rate for Payer: Aetna Commercial |
$24,801.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,699.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,605.41
|
| Rate for Payer: Cash Price |
$8,267.21
|
| Rate for Payer: Cigna Commercial |
$25,352.78
|
| Rate for Payer: Health EOS Commercial |
$24,526.06
|
| Rate for Payer: HFN Commercial |
$25,352.78
|
| Rate for Payer: Multiplan Commercial |
$22,045.90
|
| Rate for Payer: NAPHCARE Commercial |
$16,534.42
|
| Rate for Payer: Preferred Network Access Commercial |
$25,352.78
|
| Rate for Payer: Quartz Beloit One Network |
$13,503.11
|
| Rate for Payer: Quartz Commercial |
$16,534.42
|
| Rate for Payer: WEA Trust Commercial |
$15,156.55
|
| Rate for Payer: WPS Commercial |
$20,411.74
|
|
|
FEMORAL COMPONENT TRIATHLON TS SZ 4 RT 5512-F-402
|
Facility
|
OP
|
$27,557.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246163
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,716.06 |
| Max. Negotiated Rate |
$110,229.48 |
| Rate for Payer: Aetna Commercial |
$24,801.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,699.34
|
| Rate for Payer: Aetna Managed Medicare |
$7,716.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,912.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,778.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,227.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,605.41
|
| Rate for Payer: Cash Price |
$8,267.21
|
| Rate for Payer: Cigna Commercial |
$25,352.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,421.10
|
| Rate for Payer: Health EOS Commercial |
$24,526.06
|
| Rate for Payer: HFN Commercial |
$25,352.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,668.03
|
| Rate for Payer: Multiplan Commercial |
$22,045.90
|
| Rate for Payer: NAPHCARE Commercial |
$16,534.42
|
| Rate for Payer: Preferred Network Access Commercial |
$25,352.78
|
| Rate for Payer: Quartz Beloit One Network |
$13,503.11
|
| Rate for Payer: Quartz Commercial |
$17,912.29
|
| Rate for Payer: Quartz Medicare Advantage |
$16,534.42
|
| Rate for Payer: The Alliance Commercial |
$110,229.48
|
| Rate for Payer: WEA Trust Commercial |
$15,156.55
|
| Rate for Payer: WPS Commercial |
$20,411.74
|
|
|
FEMORAL COMPONENT TRIATHLON TS SZ 6 LT 5512-F-601
|
Facility
|
IP
|
$37,373.00
|
|
| Hospital Charge Code |
4100374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$18,312.77 |
| Max. Negotiated Rate |
$34,383.16 |
| Rate for Payer: Aetna Commercial |
$33,635.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32,140.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,807.69
|
| Rate for Payer: Cash Price |
$11,211.90
|
| Rate for Payer: Cigna Commercial |
$34,383.16
|
| Rate for Payer: Health EOS Commercial |
$33,261.97
|
| Rate for Payer: HFN Commercial |
$34,383.16
|
| Rate for Payer: Multiplan Commercial |
$29,898.40
|
| Rate for Payer: NAPHCARE Commercial |
$22,423.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34,383.16
|
| Rate for Payer: Quartz Beloit One Network |
$18,312.77
|
| Rate for Payer: Quartz Commercial |
$22,423.80
|
| Rate for Payer: WEA Trust Commercial |
$20,555.15
|
| Rate for Payer: WPS Commercial |
$27,682.18
|
|
|
FEMORAL COMPONENT TRIATHLON TS SZ 6 LT 5512-F-601
|
Facility
|
OP
|
$37,373.00
|
|
| Hospital Charge Code |
4100374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,464.44 |
| Max. Negotiated Rate |
$149,492.00 |
| Rate for Payer: Aetna Commercial |
$33,635.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32,140.78
|
| Rate for Payer: Aetna Managed Medicare |
$10,464.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,292.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,686.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,939.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,807.69
|
| Rate for Payer: Cash Price |
$11,211.90
|
| Rate for Payer: Cigna Commercial |
$34,383.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,913.93
|
| Rate for Payer: Health EOS Commercial |
$33,261.97
|
| Rate for Payer: HFN Commercial |
$34,383.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,029.75
|
| Rate for Payer: Multiplan Commercial |
$29,898.40
|
| Rate for Payer: NAPHCARE Commercial |
$22,423.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34,383.16
|
| Rate for Payer: Quartz Beloit One Network |
$18,312.77
|
| Rate for Payer: Quartz Commercial |
$24,292.45
|
| Rate for Payer: Quartz Medicare Advantage |
$22,423.80
|
| Rate for Payer: The Alliance Commercial |
$149,492.00
|
| Rate for Payer: WEA Trust Commercial |
$20,555.15
|
| Rate for Payer: WPS Commercial |
$27,682.18
|
|
|
FEMORAL CORTICAL STRUT 3-12MM THICK X 100MM LONG X 20MM WIDE FREEZE DRIED 400610
|
Facility
|
IP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
4509109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,539.18 |
| Max. Negotiated Rate |
$4,767.44 |
| Rate for Payer: Aetna Commercial |
$4,663.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,456.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,746.46
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,767.44
|
| Rate for Payer: Health EOS Commercial |
$4,611.98
|
| Rate for Payer: HFN Commercial |
$4,767.44
|
| Rate for Payer: Multiplan Commercial |
$4,145.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,767.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,539.18
|
| Rate for Payer: Quartz Commercial |
$3,109.20
|
| Rate for Payer: WEA Trust Commercial |
$2,850.10
|
| Rate for Payer: WPS Commercial |
$3,838.31
|
|
|
FEMORAL CORTICAL STRUT 3-12MM THICK X 100MM LONG X 20MM WIDE FREEZE DRIED 400610
|
Facility
|
OP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
4509109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,450.96 |
| Max. Negotiated Rate |
$20,728.00 |
| Rate for Payer: Aetna Commercial |
$4,663.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,456.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,450.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,368.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,591.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,487.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,746.46
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,767.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,899.85
|
| Rate for Payer: Health EOS Commercial |
$4,611.98
|
| Rate for Payer: HFN Commercial |
$4,767.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,886.50
|
| Rate for Payer: Multiplan Commercial |
$4,145.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,767.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,539.18
|
| Rate for Payer: Quartz Commercial |
$3,368.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,109.20
|
| Rate for Payer: The Alliance Commercial |
$20,728.00
|
| Rate for Payer: WEA Trust Commercial |
$2,850.10
|
| Rate for Payer: WPS Commercial |
$3,838.31
|
|
|
FEMORAL CORTICAL STRUT HALF 15CM 450485
|
Facility
|
IP
|
$6,757.00
|
|
| Hospital Charge Code |
3657496
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,310.93 |
| Max. Negotiated Rate |
$6,216.44 |
| Rate for Payer: Aetna Commercial |
$6,081.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,811.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,581.21
|
| Rate for Payer: Cash Price |
$2,027.10
|
| Rate for Payer: Cigna Commercial |
$6,216.44
|
| Rate for Payer: Health EOS Commercial |
$6,013.73
|
| Rate for Payer: HFN Commercial |
$6,216.44
|
| Rate for Payer: Multiplan Commercial |
$5,405.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,054.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,216.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,310.93
|
| Rate for Payer: Quartz Commercial |
$4,054.20
|
| Rate for Payer: WEA Trust Commercial |
$3,716.35
|
| Rate for Payer: WPS Commercial |
$5,004.91
|
|
|
FEMORAL CORTICAL STRUT HALF 15CM 450485
|
Facility
|
OP
|
$6,757.00
|
|
| Hospital Charge Code |
3657496
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,891.96 |
| Max. Negotiated Rate |
$27,028.00 |
| Rate for Payer: Aetna Commercial |
$6,081.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,811.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,891.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,392.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,378.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,243.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,581.21
|
| Rate for Payer: Cash Price |
$2,027.10
|
| Rate for Payer: Cigna Commercial |
$6,216.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,781.22
|
| Rate for Payer: Health EOS Commercial |
$6,013.73
|
| Rate for Payer: HFN Commercial |
$6,216.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,067.75
|
| Rate for Payer: Multiplan Commercial |
$5,405.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,054.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,216.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,310.93
|
| Rate for Payer: Quartz Commercial |
$4,392.05
|
| Rate for Payer: Quartz Medicare Advantage |
$4,054.20
|
| Rate for Payer: The Alliance Commercial |
$27,028.00
|
| Rate for Payer: WEA Trust Commercial |
$3,716.35
|
| Rate for Payer: WPS Commercial |
$5,004.91
|
|
|
FEMORAL CR SIGMA CEMENTED SZ 4 LT 1960-00-400
|
Facility
|
OP
|
$6,176.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,729.28 |
| Max. Negotiated Rate |
$24,704.00 |
| Rate for Payer: Aetna Commercial |
$5,558.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,311.36
|
| Rate for Payer: Aetna Managed Medicare |
$1,729.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,014.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,088.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,964.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,273.28
|
| Rate for Payer: Cash Price |
$1,852.80
|
| Rate for Payer: Cigna Commercial |
$5,681.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,456.09
|
| Rate for Payer: Health EOS Commercial |
$5,496.64
|
| Rate for Payer: HFN Commercial |
$5,681.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,632.00
|
| Rate for Payer: Multiplan Commercial |
$4,940.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,705.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,681.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,026.24
|
| Rate for Payer: Quartz Commercial |
$4,014.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,705.60
|
| Rate for Payer: The Alliance Commercial |
$24,704.00
|
| Rate for Payer: WEA Trust Commercial |
$3,396.80
|
| Rate for Payer: WPS Commercial |
$4,574.56
|
|
|
FEMORAL CR SIGMA CEMENTED SZ 4 LT 1960-00-400
|
Facility
|
IP
|
$6,176.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,026.24 |
| Max. Negotiated Rate |
$5,681.92 |
| Rate for Payer: Aetna Commercial |
$5,558.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,311.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,273.28
|
| Rate for Payer: Cash Price |
$1,852.80
|
| Rate for Payer: Cigna Commercial |
$5,681.92
|
| Rate for Payer: Health EOS Commercial |
$5,496.64
|
| Rate for Payer: HFN Commercial |
$5,681.92
|
| Rate for Payer: Multiplan Commercial |
$4,940.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,705.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,681.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,026.24
|
| Rate for Payer: Quartz Commercial |
$3,705.60
|
| Rate for Payer: WEA Trust Commercial |
$3,396.80
|
| Rate for Payer: WPS Commercial |
$4,574.56
|
|
|
FEMORAL FEMORAL BYPASS GRAFT
|
Facility
|
OP
|
$16,743.00
|
|
| Hospital Charge Code |
2960066
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,688.04 |
| Max. Negotiated Rate |
$66,972.00 |
| Rate for Payer: Aetna Commercial |
$15,068.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,398.98
|
| Rate for Payer: Aetna Managed Medicare |
$4,688.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,882.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,371.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,036.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,873.79
|
| Rate for Payer: Cash Price |
$5,022.90
|
| Rate for Payer: Cigna Commercial |
$15,403.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,369.38
|
| Rate for Payer: Health EOS Commercial |
$14,901.27
|
| Rate for Payer: HFN Commercial |
$15,403.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,557.25
|
| Rate for Payer: Multiplan Commercial |
$13,394.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,045.80
|
| Rate for Payer: Preferred Network Access Commercial |
$15,403.56
|
| Rate for Payer: Quartz Beloit One Network |
$8,204.07
|
| Rate for Payer: Quartz Commercial |
$10,882.95
|
| Rate for Payer: Quartz Medicare Advantage |
$10,045.80
|
| Rate for Payer: The Alliance Commercial |
$66,972.00
|
| Rate for Payer: WEA Trust Commercial |
$9,208.65
|
| Rate for Payer: WPS Commercial |
$12,401.54
|
|
|
FEMORAL FEMORAL BYPASS GRAFT
|
Facility
|
IP
|
$16,743.00
|
|
| Hospital Charge Code |
2960066
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,204.07 |
| Max. Negotiated Rate |
$15,403.56 |
| Rate for Payer: Aetna Commercial |
$15,068.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,398.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,873.79
|
| Rate for Payer: Cash Price |
$5,022.90
|
| Rate for Payer: Cigna Commercial |
$15,403.56
|
| Rate for Payer: Health EOS Commercial |
$14,901.27
|
| Rate for Payer: HFN Commercial |
$15,403.56
|
| Rate for Payer: Multiplan Commercial |
$13,394.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,045.80
|
| Rate for Payer: Preferred Network Access Commercial |
$15,403.56
|
| Rate for Payer: Quartz Beloit One Network |
$8,204.07
|
| Rate for Payer: Quartz Commercial |
$10,045.80
|
| Rate for Payer: WEA Trust Commercial |
$9,208.65
|
| Rate for Payer: WPS Commercial |
$12,401.54
|
|
|
FEMORAL HEAD 22MM +0 8018-22-02
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,302.84 |
| Max. Negotiated Rate |
$18,612.00 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,302.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,024.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,326.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,603.82
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,489.75
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$3,024.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,791.80
|
| Rate for Payer: The Alliance Commercial |
$18,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD 22MM +0 8018-22-02
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.97 |
| Max. Negotiated Rate |
$4,280.76 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$2,791.80
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD 22MM -2.0 8018-22-20
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,302.84 |
| Max. Negotiated Rate |
$18,612.00 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,302.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,024.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,326.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,603.82
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,489.75
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$3,024.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,791.80
|
| Rate for Payer: The Alliance Commercial |
$18,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD 22MM -2.0 8018-22-20
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.97 |
| Max. Negotiated Rate |
$4,280.76 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$2,791.80
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD 22MM +3.0 8018-22-30
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.97 |
| Max. Negotiated Rate |
$4,280.76 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$2,791.80
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD 22MM +3.0 8018-22-30
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,302.84 |
| Max. Negotiated Rate |
$18,612.00 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,302.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,024.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,326.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,603.82
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,489.75
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$3,024.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,791.80
|
| Rate for Payer: The Alliance Commercial |
$18,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD 32MM +0 8018-32-02
|
Facility
|
IP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967546
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,368.17 |
| Max. Negotiated Rate |
$4,446.36 |
| Rate for Payer: Aetna Commercial |
$4,349.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,156.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,561.49
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,446.36
|
| Rate for Payer: Health EOS Commercial |
$4,301.37
|
| Rate for Payer: HFN Commercial |
$4,446.36
|
| Rate for Payer: Multiplan Commercial |
$3,866.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,899.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,446.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,368.17
|
| Rate for Payer: Quartz Commercial |
$2,899.80
|
| Rate for Payer: WEA Trust Commercial |
$2,658.15
|
| Rate for Payer: WPS Commercial |
$3,579.80
|
|
|
FEMORAL HEAD 32MM +0 8018-32-02
|
Facility
|
OP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967546
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,353.24 |
| Max. Negotiated Rate |
$19,332.00 |
| Rate for Payer: Aetna Commercial |
$4,349.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,156.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,353.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,141.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,416.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,319.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,561.49
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,446.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,704.55
|
| Rate for Payer: Health EOS Commercial |
$4,301.37
|
| Rate for Payer: HFN Commercial |
$4,446.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,624.75
|
| Rate for Payer: Multiplan Commercial |
$3,866.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,899.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,446.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,368.17
|
| Rate for Payer: Quartz Commercial |
$3,141.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,899.80
|
| Rate for Payer: The Alliance Commercial |
$19,332.00
|
| Rate for Payer: WEA Trust Commercial |
$2,658.15
|
| Rate for Payer: WPS Commercial |
$3,579.80
|
|
|
FEMORAL HEAD 32MM +10.5 8018-32-05
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.97 |
| Max. Negotiated Rate |
$4,280.76 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$2,791.80
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD 32MM +10.5 8018-32-05
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,302.84 |
| Max. Negotiated Rate |
$18,612.00 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,302.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,024.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,326.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,603.82
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,489.75
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$3,024.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,791.80
|
| Rate for Payer: The Alliance Commercial |
$18,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD 32MM -3.5 8018-32-01
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3225465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,302.84 |
| Max. Negotiated Rate |
$18,612.00 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,302.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,024.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,326.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,603.82
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,489.75
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$3,024.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,791.80
|
| Rate for Payer: The Alliance Commercial |
$18,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
