|
FEMORAL HEAD 32MM -3.5 8018-32-01
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3225465
|
|
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 +3.5 8018-32-03
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967548
|
|
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 +3.5 8018-32-03
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967548
|
|
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 +7.0 8018-32-14
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967549
|
|
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 +7.0 8018-32-14
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967549
|
|
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 40MM +0
|
Facility
|
IP
|
$8,902.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,361.98 |
| Max. Negotiated Rate |
$8,189.84 |
| Rate for Payer: Aetna Commercial |
$8,011.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,655.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,718.06
|
| Rate for Payer: Cash Price |
$2,670.60
|
| Rate for Payer: Cigna Commercial |
$8,189.84
|
| Rate for Payer: Health EOS Commercial |
$7,922.78
|
| Rate for Payer: HFN Commercial |
$8,189.84
|
| Rate for Payer: Multiplan Commercial |
$7,121.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,341.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,189.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,361.98
|
| Rate for Payer: Quartz Commercial |
$5,341.20
|
| Rate for Payer: WEA Trust Commercial |
$4,896.10
|
| Rate for Payer: WPS Commercial |
$6,593.71
|
|
|
FEMORAL HEAD 40MM +0
|
Facility
|
OP
|
$8,902.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,492.56 |
| Max. Negotiated Rate |
$35,608.00 |
| Rate for Payer: Aetna Commercial |
$8,011.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,655.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,492.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,786.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,451.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,272.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,718.06
|
| Rate for Payer: Cash Price |
$2,670.60
|
| Rate for Payer: Cigna Commercial |
$8,189.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,981.56
|
| Rate for Payer: Health EOS Commercial |
$7,922.78
|
| Rate for Payer: HFN Commercial |
$8,189.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,676.50
|
| Rate for Payer: Multiplan Commercial |
$7,121.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,341.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,189.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,361.98
|
| Rate for Payer: Quartz Commercial |
$5,786.30
|
| Rate for Payer: Quartz Medicare Advantage |
$5,341.20
|
| Rate for Payer: The Alliance Commercial |
$35,608.00
|
| Rate for Payer: WEA Trust Commercial |
$4,896.10
|
| Rate for Payer: WPS Commercial |
$6,593.71
|
|
|
FEMORAL HEAD 40mm +3.5
|
Facility
|
IP
|
$8,912.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,366.88 |
| Max. Negotiated Rate |
$8,199.04 |
| Rate for Payer: Aetna Commercial |
$8,020.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,664.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,723.36
|
| Rate for Payer: Cash Price |
$2,673.60
|
| Rate for Payer: Cigna Commercial |
$8,199.04
|
| Rate for Payer: Health EOS Commercial |
$7,931.68
|
| Rate for Payer: HFN Commercial |
$8,199.04
|
| Rate for Payer: Multiplan Commercial |
$7,129.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,347.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,199.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,366.88
|
| Rate for Payer: Quartz Commercial |
$5,347.20
|
| Rate for Payer: WEA Trust Commercial |
$4,901.60
|
| Rate for Payer: WPS Commercial |
$6,601.12
|
|
|
FEMORAL HEAD 40mm +3.5
|
Facility
|
OP
|
$8,912.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,495.36 |
| Max. Negotiated Rate |
$35,648.00 |
| Rate for Payer: Aetna Commercial |
$8,020.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,664.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,495.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,792.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,456.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,277.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,723.36
|
| Rate for Payer: Cash Price |
$2,673.60
|
| Rate for Payer: Cigna Commercial |
$8,199.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,987.16
|
| Rate for Payer: Health EOS Commercial |
$7,931.68
|
| Rate for Payer: HFN Commercial |
$8,199.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,684.00
|
| Rate for Payer: Multiplan Commercial |
$7,129.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,347.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,199.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,366.88
|
| Rate for Payer: Quartz Commercial |
$5,792.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,347.20
|
| Rate for Payer: The Alliance Commercial |
$35,648.00
|
| Rate for Payer: WEA Trust Commercial |
$4,901.60
|
| Rate for Payer: WPS Commercial |
$6,601.12
|
|
|
FEMORAL HEAD ARTICUL/EZE 28MM +1.5 12/14 1365-11-000
|
Facility
|
IP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5490789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.32 |
| Max. Negotiated Rate |
$3,834.56 |
| Rate for Payer: Aetna Commercial |
$3,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.04
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,834.56
|
| Rate for Payer: Health EOS Commercial |
$3,709.52
|
| Rate for Payer: HFN Commercial |
$3,834.56
|
| Rate for Payer: Multiplan Commercial |
$3,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.32
|
| Rate for Payer: Quartz Commercial |
$2,500.80
|
| Rate for Payer: WEA Trust Commercial |
$2,292.40
|
| Rate for Payer: WPS Commercial |
$3,087.24
|
|
|
FEMORAL HEAD ARTICUL/EZE 28MM +1.5 12/14 1365-11-000
|
Facility
|
OP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5490789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.04 |
| Max. Negotiated Rate |
$16,672.00 |
| Rate for Payer: Aetna Commercial |
$3,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,709.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,084.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,000.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.04
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,834.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,332.41
|
| Rate for Payer: Health EOS Commercial |
$3,709.52
|
| Rate for Payer: HFN Commercial |
$3,834.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,126.00
|
| Rate for Payer: Multiplan Commercial |
$3,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.32
|
| Rate for Payer: Quartz Commercial |
$2,709.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,500.80
|
| Rate for Payer: The Alliance Commercial |
$16,672.00
|
| Rate for Payer: WEA Trust Commercial |
$2,292.40
|
| Rate for Payer: WPS Commercial |
$3,087.24
|
|
|
FEMORAL HEAD ARTICUL/EZE 28MM +5 12/14 1365-12-000
|
Facility
|
OP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5544766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.84 |
| Max. Negotiated Rate |
$19,912.00 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,235.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,785.69
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.50
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$3,235.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,986.80
|
| Rate for Payer: The Alliance Commercial |
$19,912.00
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
FEMORAL HEAD ARTICUL/EZE 28MM +5 12/14 1365-12-000
|
Facility
|
IP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5544766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.22 |
| Max. Negotiated Rate |
$4,579.76 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$2,986.80
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +1.0 12/14 1365-21-000
|
Facility
|
OP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520945
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.84 |
| Max. Negotiated Rate |
$19,912.00 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,235.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,785.69
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.50
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$3,235.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,986.80
|
| Rate for Payer: The Alliance Commercial |
$19,912.00
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +1.0 12/14 1365-21-000
|
Facility
|
IP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520945
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.22 |
| Max. Negotiated Rate |
$4,579.76 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$2,986.80
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +5 12/14 1365-22-000
|
Facility
|
IP
|
$5,170.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459308
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,533.30 |
| Max. Negotiated Rate |
$4,756.40 |
| Rate for Payer: Aetna Commercial |
$4,653.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,446.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,740.10
|
| Rate for Payer: Cash Price |
$1,551.00
|
| Rate for Payer: Cigna Commercial |
$4,756.40
|
| Rate for Payer: Health EOS Commercial |
$4,601.30
|
| Rate for Payer: HFN Commercial |
$4,756.40
|
| Rate for Payer: Multiplan Commercial |
$4,136.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,756.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,533.30
|
| Rate for Payer: Quartz Commercial |
$3,102.00
|
| Rate for Payer: WEA Trust Commercial |
$2,843.50
|
| Rate for Payer: WPS Commercial |
$3,829.42
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +5 12/14 1365-22-000
|
Facility
|
OP
|
$5,170.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459308
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,447.60 |
| Max. Negotiated Rate |
$20,680.00 |
| Rate for Payer: Aetna Commercial |
$4,653.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,446.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,447.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,360.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,585.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,481.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,740.10
|
| Rate for Payer: Cash Price |
$1,551.00
|
| Rate for Payer: Cigna Commercial |
$4,756.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,893.13
|
| Rate for Payer: Health EOS Commercial |
$4,601.30
|
| Rate for Payer: HFN Commercial |
$4,756.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,877.50
|
| Rate for Payer: Multiplan Commercial |
$4,136.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,756.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,533.30
|
| Rate for Payer: Quartz Commercial |
$3,360.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,102.00
|
| Rate for Payer: The Alliance Commercial |
$20,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,843.50
|
| Rate for Payer: WPS Commercial |
$3,829.42
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +9 12/14 1365-23-000
|
Facility
|
IP
|
$4,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,963.92 |
| Max. Negotiated Rate |
$3,687.36 |
| Rate for Payer: Aetna Commercial |
$3,607.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,446.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,124.24
|
| Rate for Payer: Cash Price |
$1,202.40
|
| Rate for Payer: Cigna Commercial |
$3,687.36
|
| Rate for Payer: Health EOS Commercial |
$3,567.12
|
| Rate for Payer: HFN Commercial |
$3,687.36
|
| Rate for Payer: Multiplan Commercial |
$3,206.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,404.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,687.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,963.92
|
| Rate for Payer: Quartz Commercial |
$2,404.80
|
| Rate for Payer: WEA Trust Commercial |
$2,204.40
|
| Rate for Payer: WPS Commercial |
$2,968.73
|
|
|
FEMORAL HEAD ARTICUL/EZE 32MM +9 12/14 1365-23-000
|
Facility
|
OP
|
$4,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729879
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,122.24 |
| Max. Negotiated Rate |
$16,032.00 |
| Rate for Payer: Aetna Commercial |
$3,607.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,446.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,122.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,605.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,004.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,923.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,124.24
|
| Rate for Payer: Cash Price |
$1,202.40
|
| Rate for Payer: Cigna Commercial |
$3,687.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,242.88
|
| Rate for Payer: Health EOS Commercial |
$3,567.12
|
| Rate for Payer: HFN Commercial |
$3,687.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,006.00
|
| Rate for Payer: Multiplan Commercial |
$3,206.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,404.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,687.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,963.92
|
| Rate for Payer: Quartz Commercial |
$2,605.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,404.80
|
| Rate for Payer: The Alliance Commercial |
$16,032.00
|
| Rate for Payer: WEA Trust Commercial |
$2,204.40
|
| Rate for Payer: WPS Commercial |
$2,968.73
|
|
|
FEMORAL HEAD BIOLOX 40MM 6519-1-040
|
Facility
|
OP
|
$6,709.00
|
|
| Hospital Charge Code |
3779521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.52 |
| Max. Negotiated Rate |
$26,836.00 |
| Rate for Payer: Aetna Commercial |
$6,038.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,769.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,220.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.77
|
| Rate for Payer: Cash Price |
$2,012.70
|
| Rate for Payer: Cigna Commercial |
$6,172.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,754.36
|
| Rate for Payer: Health EOS Commercial |
$5,971.01
|
| Rate for Payer: HFN Commercial |
$6,172.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.75
|
| Rate for Payer: Multiplan Commercial |
$5,367.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,025.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,172.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,287.41
|
| Rate for Payer: Quartz Commercial |
$4,360.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,025.40
|
| Rate for Payer: The Alliance Commercial |
$26,836.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.95
|
| Rate for Payer: WPS Commercial |
$4,969.36
|
|
|
FEMORAL HEAD BIOLOX 40MM 6519-1-040
|
Facility
|
IP
|
$6,709.00
|
|
| Hospital Charge Code |
3779521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,287.41 |
| Max. Negotiated Rate |
$6,172.28 |
| Rate for Payer: Aetna Commercial |
$6,038.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,769.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.77
|
| Rate for Payer: Cash Price |
$2,012.70
|
| Rate for Payer: Cigna Commercial |
$6,172.28
|
| Rate for Payer: Health EOS Commercial |
$5,971.01
|
| Rate for Payer: HFN Commercial |
$6,172.28
|
| Rate for Payer: Multiplan Commercial |
$5,367.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,025.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,172.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,287.41
|
| Rate for Payer: Quartz Commercial |
$4,025.40
|
| Rate for Payer: WEA Trust Commercial |
$3,689.95
|
| Rate for Payer: WPS Commercial |
$4,969.36
|
|
|
FEMORAL HEAD BIOLOX 44MM 6519-1-044
|
Facility
|
IP
|
$6,709.00
|
|
| Hospital Charge Code |
4263461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,287.41 |
| Max. Negotiated Rate |
$6,172.28 |
| Rate for Payer: Aetna Commercial |
$6,038.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,769.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.77
|
| Rate for Payer: Cash Price |
$2,012.70
|
| Rate for Payer: Cigna Commercial |
$6,172.28
|
| Rate for Payer: Health EOS Commercial |
$5,971.01
|
| Rate for Payer: HFN Commercial |
$6,172.28
|
| Rate for Payer: Multiplan Commercial |
$5,367.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,025.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,172.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,287.41
|
| Rate for Payer: Quartz Commercial |
$4,025.40
|
| Rate for Payer: WEA Trust Commercial |
$3,689.95
|
| Rate for Payer: WPS Commercial |
$4,969.36
|
|
|
FEMORAL HEAD BIOLOX 44MM 6519-1-044
|
Facility
|
OP
|
$6,709.00
|
|
| Hospital Charge Code |
4263461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.52 |
| Max. Negotiated Rate |
$26,836.00 |
| Rate for Payer: Aetna Commercial |
$6,038.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,769.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,220.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.77
|
| Rate for Payer: Cash Price |
$2,012.70
|
| Rate for Payer: Cigna Commercial |
$6,172.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,754.36
|
| Rate for Payer: Health EOS Commercial |
$5,971.01
|
| Rate for Payer: HFN Commercial |
$6,172.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.75
|
| Rate for Payer: Multiplan Commercial |
$5,367.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,025.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,172.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,287.41
|
| Rate for Payer: Quartz Commercial |
$4,360.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,025.40
|
| Rate for Payer: The Alliance Commercial |
$26,836.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.95
|
| Rate for Payer: WPS Commercial |
$4,969.36
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 32MM +1.0 12/14 1365-32-310
|
Facility
|
OP
|
$5,850.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563227
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,638.00 |
| Max. Negotiated Rate |
$23,400.00 |
| Rate for Payer: Aetna Commercial |
$5,265.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,031.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,638.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,802.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,925.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,808.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,100.50
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cigna Commercial |
$5,382.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,273.66
|
| Rate for Payer: Health EOS Commercial |
$5,206.50
|
| Rate for Payer: HFN Commercial |
$5,382.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,387.50
|
| Rate for Payer: Multiplan Commercial |
$4,680.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,510.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,382.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,866.50
|
| Rate for Payer: Quartz Commercial |
$3,802.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,510.00
|
| Rate for Payer: The Alliance Commercial |
$23,400.00
|
| Rate for Payer: WEA Trust Commercial |
$3,217.50
|
| Rate for Payer: WPS Commercial |
$4,333.10
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 32MM +1.0 12/14 1365-32-310
|
Facility
|
IP
|
$5,850.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563227
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,866.50 |
| Max. Negotiated Rate |
$5,382.00 |
| Rate for Payer: Aetna Commercial |
$5,265.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,031.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,100.50
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cigna Commercial |
$5,382.00
|
| Rate for Payer: Health EOS Commercial |
$5,206.50
|
| Rate for Payer: HFN Commercial |
$5,382.00
|
| Rate for Payer: Multiplan Commercial |
$4,680.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,510.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,382.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,866.50
|
| Rate for Payer: Quartz Commercial |
$3,510.00
|
| Rate for Payer: WEA Trust Commercial |
$3,217.50
|
| Rate for Payer: WPS Commercial |
$4,333.10
|
|
