|
FEMORAL POSTERIOR STABILIZED ATTUNE SZ 8 RT CEMENTED 1504-10-208
|
Facility
|
OP
|
$8,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496863
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.21 |
| Max. Negotiated Rate |
$7,860.11 |
| Rate for Payer: Aetna Commercial |
$7,689.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,347.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,392.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,553.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,271.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,100.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,528.11
|
| Rate for Payer: Cash Price |
$2,464.50
|
| Rate for Payer: Cigna Commercial |
$7,860.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,781.13
|
| Rate for Payer: Health EOS Commercial |
$7,603.80
|
| Rate for Payer: HFN Commercial |
$7,860.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,407.70
|
| Rate for Payer: Multiplan Commercial |
$6,834.88
|
| Rate for Payer: NAPHCARE Commercial |
$5,126.16
|
| Rate for Payer: Preferred Network Access Commercial |
$7,860.11
|
| Rate for Payer: Quartz Beloit One Network |
$4,186.36
|
| Rate for Payer: Quartz Commercial |
$5,553.34
|
| Rate for Payer: Quartz Medicare Advantage |
$5,126.16
|
| Rate for Payer: The Alliance Commercial |
$4,271.80
|
| Rate for Payer: WEA Trust Commercial |
$4,698.98
|
| Rate for Payer: WPS Commercial |
$6,328.01
|
|
|
FEMORAL POSTERIOR STABILIZED ATTUNE SZ 9 RT CEMENTED 1504-10-209
|
Facility
|
OP
|
$7,910.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5497056
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,303.39 |
| Max. Negotiated Rate |
$7,568.29 |
| Rate for Payer: Aetna Commercial |
$7,403.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,074.70
|
| Rate for Payer: Aetna Managed Medicare |
$2,303.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,347.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,113.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,948.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,359.99
|
| Rate for Payer: Cash Price |
$2,373.00
|
| Rate for Payer: Cigna Commercial |
$7,568.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,603.62
|
| Rate for Payer: Health EOS Commercial |
$7,321.50
|
| Rate for Payer: HFN Commercial |
$7,568.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,169.80
|
| Rate for Payer: Multiplan Commercial |
$6,581.12
|
| Rate for Payer: NAPHCARE Commercial |
$4,935.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,568.29
|
| Rate for Payer: Quartz Beloit One Network |
$4,030.94
|
| Rate for Payer: Quartz Commercial |
$5,347.16
|
| Rate for Payer: Quartz Medicare Advantage |
$4,935.84
|
| Rate for Payer: The Alliance Commercial |
$4,113.20
|
| Rate for Payer: WEA Trust Commercial |
$4,524.52
|
| Rate for Payer: WPS Commercial |
$6,093.07
|
|
|
FEMORAL POSTERIOR STABILIZED ATTUNE SZ 9 RT CEMENTED 1504-10-209
|
Facility
|
IP
|
$7,910.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5497056
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,030.94 |
| Max. Negotiated Rate |
$7,568.29 |
| Rate for Payer: Aetna Commercial |
$7,403.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,074.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,359.99
|
| Rate for Payer: Cash Price |
$2,373.00
|
| Rate for Payer: Cigna Commercial |
$7,568.29
|
| Rate for Payer: Health EOS Commercial |
$7,321.50
|
| Rate for Payer: HFN Commercial |
$7,568.29
|
| Rate for Payer: Multiplan Commercial |
$6,581.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,568.29
|
| Rate for Payer: Quartz Beloit One Network |
$4,030.94
|
| Rate for Payer: Quartz Commercial |
$4,935.84
|
| Rate for Payer: WEA Trust Commercial |
$4,524.52
|
| Rate for Payer: WPS Commercial |
$6,093.07
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 3 RT CEMENTED 1504-40-203
|
Facility
|
OP
|
$47,672.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,882.09 |
| Max. Negotiated Rate |
$45,612.57 |
| Rate for Payer: Aetna Commercial |
$44,620.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42,637.84
|
| Rate for Payer: Aetna Managed Medicare |
$13,882.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32,226.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,789.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,797.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26,276.81
|
| Rate for Payer: Cash Price |
$14,301.60
|
| Rate for Payer: Cigna Commercial |
$45,612.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,745.10
|
| Rate for Payer: Health EOS Commercial |
$44,125.20
|
| Rate for Payer: HFN Commercial |
$45,612.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,184.16
|
| Rate for Payer: Multiplan Commercial |
$39,663.10
|
| Rate for Payer: NAPHCARE Commercial |
$29,747.33
|
| Rate for Payer: Preferred Network Access Commercial |
$45,612.57
|
| Rate for Payer: Quartz Beloit One Network |
$24,293.65
|
| Rate for Payer: Quartz Commercial |
$32,226.27
|
| Rate for Payer: Quartz Medicare Advantage |
$29,747.33
|
| Rate for Payer: The Alliance Commercial |
$24,789.44
|
| Rate for Payer: WEA Trust Commercial |
$27,268.38
|
| Rate for Payer: WPS Commercial |
$36,721.74
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 3 RT CEMENTED 1504-40-203
|
Facility
|
IP
|
$47,672.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24,293.65 |
| Max. Negotiated Rate |
$45,612.57 |
| Rate for Payer: Aetna Commercial |
$44,620.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42,637.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26,276.81
|
| Rate for Payer: Cash Price |
$14,301.60
|
| Rate for Payer: Cigna Commercial |
$45,612.57
|
| Rate for Payer: Health EOS Commercial |
$44,125.20
|
| Rate for Payer: HFN Commercial |
$45,612.57
|
| Rate for Payer: Multiplan Commercial |
$39,663.10
|
| Rate for Payer: Preferred Network Access Commercial |
$45,612.57
|
| Rate for Payer: Quartz Beloit One Network |
$24,293.65
|
| Rate for Payer: Quartz Commercial |
$29,747.33
|
| Rate for Payer: WEA Trust Commercial |
$27,268.38
|
| Rate for Payer: WPS Commercial |
$36,721.74
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 4 LT CEMENTED 1504-40-104
|
Facility
|
OP
|
$31,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6177673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,300.93 |
| Max. Negotiated Rate |
$30,560.19 |
| Rate for Payer: Aetna Commercial |
$29,895.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,567.14
|
| Rate for Payer: Aetna Managed Medicare |
$9,300.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,591.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,608.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,944.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,605.33
|
| Rate for Payer: Cash Price |
$9,582.00
|
| Rate for Payer: Cigna Commercial |
$30,560.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,589.08
|
| Rate for Payer: Health EOS Commercial |
$29,563.66
|
| Rate for Payer: HFN Commercial |
$30,560.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,913.20
|
| Rate for Payer: Multiplan Commercial |
$26,574.08
|
| Rate for Payer: NAPHCARE Commercial |
$19,930.56
|
| Rate for Payer: Preferred Network Access Commercial |
$30,560.19
|
| Rate for Payer: Quartz Beloit One Network |
$16,276.62
|
| Rate for Payer: Quartz Commercial |
$21,591.44
|
| Rate for Payer: Quartz Medicare Advantage |
$19,930.56
|
| Rate for Payer: The Alliance Commercial |
$16,608.80
|
| Rate for Payer: WEA Trust Commercial |
$18,269.68
|
| Rate for Payer: WPS Commercial |
$24,603.38
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 4 LT CEMENTED 1504-40-104
|
Facility
|
IP
|
$31,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6177673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,276.62 |
| Max. Negotiated Rate |
$30,560.19 |
| Rate for Payer: Aetna Commercial |
$29,895.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,567.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,605.33
|
| Rate for Payer: Cash Price |
$9,582.00
|
| Rate for Payer: Cigna Commercial |
$30,560.19
|
| Rate for Payer: Health EOS Commercial |
$29,563.66
|
| Rate for Payer: HFN Commercial |
$30,560.19
|
| Rate for Payer: Multiplan Commercial |
$26,574.08
|
| Rate for Payer: Preferred Network Access Commercial |
$30,560.19
|
| Rate for Payer: Quartz Beloit One Network |
$16,276.62
|
| Rate for Payer: Quartz Commercial |
$19,930.56
|
| Rate for Payer: WEA Trust Commercial |
$18,269.68
|
| Rate for Payer: WPS Commercial |
$24,603.38
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 4 LT CEMENTED 1504-40-205
|
Facility
|
IP
|
$31,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6151662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,276.62 |
| Max. Negotiated Rate |
$30,560.19 |
| Rate for Payer: Aetna Commercial |
$29,895.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,567.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,605.33
|
| Rate for Payer: Cash Price |
$9,582.00
|
| Rate for Payer: Cigna Commercial |
$30,560.19
|
| Rate for Payer: Health EOS Commercial |
$29,563.66
|
| Rate for Payer: HFN Commercial |
$30,560.19
|
| Rate for Payer: Multiplan Commercial |
$26,574.08
|
| Rate for Payer: Preferred Network Access Commercial |
$30,560.19
|
| Rate for Payer: Quartz Beloit One Network |
$16,276.62
|
| Rate for Payer: Quartz Commercial |
$19,930.56
|
| Rate for Payer: WEA Trust Commercial |
$18,269.68
|
| Rate for Payer: WPS Commercial |
$24,603.38
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 4 LT CEMENTED 1504-40-205
|
Facility
|
OP
|
$31,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6151662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,300.93 |
| Max. Negotiated Rate |
$30,560.19 |
| Rate for Payer: Aetna Commercial |
$29,895.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,567.14
|
| Rate for Payer: Aetna Managed Medicare |
$9,300.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,591.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,608.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,944.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,605.33
|
| Rate for Payer: Cash Price |
$9,582.00
|
| Rate for Payer: Cigna Commercial |
$30,560.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,589.08
|
| Rate for Payer: Health EOS Commercial |
$29,563.66
|
| Rate for Payer: HFN Commercial |
$30,560.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,913.20
|
| Rate for Payer: Multiplan Commercial |
$26,574.08
|
| Rate for Payer: NAPHCARE Commercial |
$19,930.56
|
| Rate for Payer: Preferred Network Access Commercial |
$30,560.19
|
| Rate for Payer: Quartz Beloit One Network |
$16,276.62
|
| Rate for Payer: Quartz Commercial |
$21,591.44
|
| Rate for Payer: Quartz Medicare Advantage |
$19,930.56
|
| Rate for Payer: The Alliance Commercial |
$16,608.80
|
| Rate for Payer: WEA Trust Commercial |
$18,269.68
|
| Rate for Payer: WPS Commercial |
$24,603.38
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 4 RT CEMENTED 1504-40-204
|
Facility
|
OP
|
$49,378.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,378.87 |
| Max. Negotiated Rate |
$47,244.87 |
| Rate for Payer: Aetna Commercial |
$46,217.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44,163.68
|
| Rate for Payer: Aetna Managed Medicare |
$14,378.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,379.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,676.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,649.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27,217.15
|
| Rate for Payer: Cash Price |
$14,813.40
|
| Rate for Payer: Cigna Commercial |
$47,244.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,738.00
|
| Rate for Payer: Health EOS Commercial |
$45,704.28
|
| Rate for Payer: HFN Commercial |
$47,244.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,514.84
|
| Rate for Payer: Multiplan Commercial |
$41,082.50
|
| Rate for Payer: NAPHCARE Commercial |
$30,811.87
|
| Rate for Payer: Preferred Network Access Commercial |
$47,244.87
|
| Rate for Payer: Quartz Beloit One Network |
$25,163.03
|
| Rate for Payer: Quartz Commercial |
$33,379.53
|
| Rate for Payer: Quartz Medicare Advantage |
$30,811.87
|
| Rate for Payer: The Alliance Commercial |
$25,676.56
|
| Rate for Payer: WEA Trust Commercial |
$28,244.22
|
| Rate for Payer: WPS Commercial |
$38,035.87
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 4 RT CEMENTED 1504-40-204
|
Facility
|
IP
|
$49,378.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,163.03 |
| Max. Negotiated Rate |
$47,244.87 |
| Rate for Payer: Aetna Commercial |
$46,217.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44,163.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27,217.15
|
| Rate for Payer: Cash Price |
$14,813.40
|
| Rate for Payer: Cigna Commercial |
$47,244.87
|
| Rate for Payer: Health EOS Commercial |
$45,704.28
|
| Rate for Payer: HFN Commercial |
$47,244.87
|
| Rate for Payer: Multiplan Commercial |
$41,082.50
|
| Rate for Payer: Preferred Network Access Commercial |
$47,244.87
|
| Rate for Payer: Quartz Beloit One Network |
$25,163.03
|
| Rate for Payer: Quartz Commercial |
$30,811.87
|
| Rate for Payer: WEA Trust Commercial |
$28,244.22
|
| Rate for Payer: WPS Commercial |
$38,035.87
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 5 LT CEMENTED 1504-40-105
|
Facility
|
OP
|
$33,814.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6226145
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,846.64 |
| Max. Negotiated Rate |
$32,353.24 |
| Rate for Payer: Aetna Commercial |
$31,649.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,243.24
|
| Rate for Payer: Aetna Managed Medicare |
$9,846.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,858.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,583.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,879.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,638.28
|
| Rate for Payer: Cash Price |
$10,144.20
|
| Rate for Payer: Cigna Commercial |
$32,353.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,679.75
|
| Rate for Payer: Health EOS Commercial |
$31,298.24
|
| Rate for Payer: HFN Commercial |
$32,353.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,374.92
|
| Rate for Payer: Multiplan Commercial |
$28,133.25
|
| Rate for Payer: NAPHCARE Commercial |
$21,099.94
|
| Rate for Payer: Preferred Network Access Commercial |
$32,353.24
|
| Rate for Payer: Quartz Beloit One Network |
$17,231.61
|
| Rate for Payer: Quartz Commercial |
$22,858.26
|
| Rate for Payer: Quartz Medicare Advantage |
$21,099.94
|
| Rate for Payer: The Alliance Commercial |
$17,583.28
|
| Rate for Payer: WEA Trust Commercial |
$19,341.61
|
| Rate for Payer: WPS Commercial |
$26,046.92
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 5 LT CEMENTED 1504-40-105
|
Facility
|
IP
|
$33,814.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6226145
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17,231.61 |
| Max. Negotiated Rate |
$32,353.24 |
| Rate for Payer: Aetna Commercial |
$31,649.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,243.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,638.28
|
| Rate for Payer: Cash Price |
$10,144.20
|
| Rate for Payer: Cigna Commercial |
$32,353.24
|
| Rate for Payer: Health EOS Commercial |
$31,298.24
|
| Rate for Payer: HFN Commercial |
$32,353.24
|
| Rate for Payer: Multiplan Commercial |
$28,133.25
|
| Rate for Payer: Preferred Network Access Commercial |
$32,353.24
|
| Rate for Payer: Quartz Beloit One Network |
$17,231.61
|
| Rate for Payer: Quartz Commercial |
$21,099.94
|
| Rate for Payer: WEA Trust Commercial |
$19,341.61
|
| Rate for Payer: WPS Commercial |
$26,046.92
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 6 RT CEMENTED 1504-40-206
|
Facility
|
OP
|
$30,712.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6201076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,943.33 |
| Max. Negotiated Rate |
$29,385.24 |
| Rate for Payer: Aetna Commercial |
$28,746.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,468.81
|
| Rate for Payer: Aetna Managed Medicare |
$8,943.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,761.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,970.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,331.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,928.45
|
| Rate for Payer: Cash Price |
$9,213.60
|
| Rate for Payer: Cigna Commercial |
$29,385.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,874.38
|
| Rate for Payer: Health EOS Commercial |
$28,427.03
|
| Rate for Payer: HFN Commercial |
$29,385.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,955.36
|
| Rate for Payer: Multiplan Commercial |
$25,552.38
|
| Rate for Payer: NAPHCARE Commercial |
$19,164.29
|
| Rate for Payer: Preferred Network Access Commercial |
$29,385.24
|
| Rate for Payer: Quartz Beloit One Network |
$15,650.84
|
| Rate for Payer: Quartz Commercial |
$20,761.31
|
| Rate for Payer: Quartz Medicare Advantage |
$19,164.29
|
| Rate for Payer: The Alliance Commercial |
$15,970.24
|
| Rate for Payer: WEA Trust Commercial |
$17,567.26
|
| Rate for Payer: WPS Commercial |
$23,657.45
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 6 RT CEMENTED 1504-40-206
|
Facility
|
IP
|
$30,712.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6201076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,650.84 |
| Max. Negotiated Rate |
$29,385.24 |
| Rate for Payer: Aetna Commercial |
$28,746.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,468.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,928.45
|
| Rate for Payer: Cash Price |
$9,213.60
|
| Rate for Payer: Cigna Commercial |
$29,385.24
|
| Rate for Payer: Health EOS Commercial |
$28,427.03
|
| Rate for Payer: HFN Commercial |
$29,385.24
|
| Rate for Payer: Multiplan Commercial |
$25,552.38
|
| Rate for Payer: Preferred Network Access Commercial |
$29,385.24
|
| Rate for Payer: Quartz Beloit One Network |
$15,650.84
|
| Rate for Payer: Quartz Commercial |
$19,164.29
|
| Rate for Payer: WEA Trust Commercial |
$17,567.26
|
| Rate for Payer: WPS Commercial |
$23,657.45
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 7 LT CEMENTED 1504-40-107
|
Facility
|
OP
|
$31,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6165875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,300.93 |
| Max. Negotiated Rate |
$30,560.19 |
| Rate for Payer: Aetna Commercial |
$29,895.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,567.14
|
| Rate for Payer: Aetna Managed Medicare |
$9,300.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,591.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,608.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,944.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,605.33
|
| Rate for Payer: Cash Price |
$9,582.00
|
| Rate for Payer: Cigna Commercial |
$30,560.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,589.08
|
| Rate for Payer: Health EOS Commercial |
$29,563.66
|
| Rate for Payer: HFN Commercial |
$30,560.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,913.20
|
| Rate for Payer: Multiplan Commercial |
$26,574.08
|
| Rate for Payer: NAPHCARE Commercial |
$19,930.56
|
| Rate for Payer: Preferred Network Access Commercial |
$30,560.19
|
| Rate for Payer: Quartz Beloit One Network |
$16,276.62
|
| Rate for Payer: Quartz Commercial |
$21,591.44
|
| Rate for Payer: Quartz Medicare Advantage |
$19,930.56
|
| Rate for Payer: The Alliance Commercial |
$16,608.80
|
| Rate for Payer: WEA Trust Commercial |
$18,269.68
|
| Rate for Payer: WPS Commercial |
$24,603.38
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 7 LT CEMENTED 1504-40-107
|
Facility
|
IP
|
$31,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6165875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,276.62 |
| Max. Negotiated Rate |
$30,560.19 |
| Rate for Payer: Aetna Commercial |
$29,895.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,567.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,605.33
|
| Rate for Payer: Cash Price |
$9,582.00
|
| Rate for Payer: Cigna Commercial |
$30,560.19
|
| Rate for Payer: Health EOS Commercial |
$29,563.66
|
| Rate for Payer: HFN Commercial |
$30,560.19
|
| Rate for Payer: Multiplan Commercial |
$26,574.08
|
| Rate for Payer: Preferred Network Access Commercial |
$30,560.19
|
| Rate for Payer: Quartz Beloit One Network |
$16,276.62
|
| Rate for Payer: Quartz Commercial |
$19,930.56
|
| Rate for Payer: WEA Trust Commercial |
$18,269.68
|
| Rate for Payer: WPS Commercial |
$24,603.38
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 7 RT CEMENTED 1504-40-207
|
Facility
|
OP
|
$49,378.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,378.87 |
| Max. Negotiated Rate |
$47,244.87 |
| Rate for Payer: Aetna Commercial |
$46,217.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44,163.68
|
| Rate for Payer: Aetna Managed Medicare |
$14,378.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,379.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,676.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,649.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27,217.15
|
| Rate for Payer: Cash Price |
$14,813.40
|
| Rate for Payer: Cigna Commercial |
$47,244.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,738.00
|
| Rate for Payer: Health EOS Commercial |
$45,704.28
|
| Rate for Payer: HFN Commercial |
$47,244.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,514.84
|
| Rate for Payer: Multiplan Commercial |
$41,082.50
|
| Rate for Payer: NAPHCARE Commercial |
$30,811.87
|
| Rate for Payer: Preferred Network Access Commercial |
$47,244.87
|
| Rate for Payer: Quartz Beloit One Network |
$25,163.03
|
| Rate for Payer: Quartz Commercial |
$33,379.53
|
| Rate for Payer: Quartz Medicare Advantage |
$30,811.87
|
| Rate for Payer: The Alliance Commercial |
$25,676.56
|
| Rate for Payer: WEA Trust Commercial |
$28,244.22
|
| Rate for Payer: WPS Commercial |
$38,035.87
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 7 RT CEMENTED 1504-40-207
|
Facility
|
IP
|
$49,378.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,163.03 |
| Max. Negotiated Rate |
$47,244.87 |
| Rate for Payer: Aetna Commercial |
$46,217.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44,163.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27,217.15
|
| Rate for Payer: Cash Price |
$14,813.40
|
| Rate for Payer: Cigna Commercial |
$47,244.87
|
| Rate for Payer: Health EOS Commercial |
$45,704.28
|
| Rate for Payer: HFN Commercial |
$47,244.87
|
| Rate for Payer: Multiplan Commercial |
$41,082.50
|
| Rate for Payer: Preferred Network Access Commercial |
$47,244.87
|
| Rate for Payer: Quartz Beloit One Network |
$25,163.03
|
| Rate for Payer: Quartz Commercial |
$30,811.87
|
| Rate for Payer: WEA Trust Commercial |
$28,244.22
|
| Rate for Payer: WPS Commercial |
$38,035.87
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 8 RT CEMENTED 1504-40-208
|
Facility
|
OP
|
$33,218.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,673.08 |
| Max. Negotiated Rate |
$31,782.98 |
| Rate for Payer: Aetna Commercial |
$31,092.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29,710.18
|
| Rate for Payer: Aetna Managed Medicare |
$9,673.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,455.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,273.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,582.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,309.76
|
| Rate for Payer: Cash Price |
$9,965.40
|
| Rate for Payer: Cigna Commercial |
$31,782.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,332.88
|
| Rate for Payer: Health EOS Commercial |
$30,746.58
|
| Rate for Payer: HFN Commercial |
$31,782.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,910.04
|
| Rate for Payer: Multiplan Commercial |
$27,637.38
|
| Rate for Payer: NAPHCARE Commercial |
$20,728.03
|
| Rate for Payer: Preferred Network Access Commercial |
$31,782.98
|
| Rate for Payer: Quartz Beloit One Network |
$16,927.89
|
| Rate for Payer: Quartz Commercial |
$22,455.37
|
| Rate for Payer: Quartz Medicare Advantage |
$20,728.03
|
| Rate for Payer: The Alliance Commercial |
$17,273.36
|
| Rate for Payer: WEA Trust Commercial |
$19,000.70
|
| Rate for Payer: WPS Commercial |
$25,587.83
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 8 RT CEMENTED 1504-40-208
|
Facility
|
IP
|
$33,218.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,927.89 |
| Max. Negotiated Rate |
$31,782.98 |
| Rate for Payer: Aetna Commercial |
$31,092.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29,710.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,309.76
|
| Rate for Payer: Cash Price |
$9,965.40
|
| Rate for Payer: Cigna Commercial |
$31,782.98
|
| Rate for Payer: Health EOS Commercial |
$30,746.58
|
| Rate for Payer: HFN Commercial |
$31,782.98
|
| Rate for Payer: Multiplan Commercial |
$27,637.38
|
| Rate for Payer: Preferred Network Access Commercial |
$31,782.98
|
| Rate for Payer: Quartz Beloit One Network |
$16,927.89
|
| Rate for Payer: Quartz Commercial |
$20,728.03
|
| Rate for Payer: WEA Trust Commercial |
$19,000.70
|
| Rate for Payer: WPS Commercial |
$25,587.83
|
|
|
FEMORAL ROTATING HINGE CEMENTED LT X-SMALL S-ROM NOILES 62-3421L
|
Facility
|
OP
|
$32,339.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,417.12 |
| Max. Negotiated Rate |
$30,941.96 |
| Rate for Payer: Aetna Commercial |
$30,269.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,924.00
|
| Rate for Payer: Aetna Managed Medicare |
$9,417.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,861.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,816.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,143.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,825.26
|
| Rate for Payer: Cash Price |
$9,701.70
|
| Rate for Payer: Cigna Commercial |
$30,941.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,821.30
|
| Rate for Payer: Health EOS Commercial |
$29,932.98
|
| Rate for Payer: HFN Commercial |
$30,941.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,224.42
|
| Rate for Payer: Multiplan Commercial |
$26,906.05
|
| Rate for Payer: NAPHCARE Commercial |
$20,179.54
|
| Rate for Payer: Preferred Network Access Commercial |
$30,941.96
|
| Rate for Payer: Quartz Beloit One Network |
$16,479.95
|
| Rate for Payer: Quartz Commercial |
$21,861.16
|
| Rate for Payer: Quartz Medicare Advantage |
$20,179.54
|
| Rate for Payer: The Alliance Commercial |
$16,816.28
|
| Rate for Payer: WEA Trust Commercial |
$18,497.91
|
| Rate for Payer: WPS Commercial |
$24,910.73
|
|
|
FEMORAL ROTATING HINGE CEMENTED LT X-SMALL S-ROM NOILES 62-3421L
|
Facility
|
IP
|
$32,339.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,479.95 |
| Max. Negotiated Rate |
$30,941.96 |
| Rate for Payer: WPS Commercial |
$24,910.73
|
| Rate for Payer: Aetna Commercial |
$30,269.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,924.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,825.26
|
| Rate for Payer: Cash Price |
$9,701.70
|
| Rate for Payer: Cigna Commercial |
$30,941.96
|
| Rate for Payer: Health EOS Commercial |
$29,932.98
|
| Rate for Payer: HFN Commercial |
$30,941.96
|
| Rate for Payer: Multiplan Commercial |
$26,906.05
|
| Rate for Payer: Preferred Network Access Commercial |
$30,941.96
|
| Rate for Payer: Quartz Beloit One Network |
$16,479.95
|
| Rate for Payer: Quartz Commercial |
$20,179.54
|
| Rate for Payer: WEA Trust Commercial |
$18,497.91
|
|
|
FEMORAL ROTATING HINGE NEXGEN CEMENTED RT SZ D 00-5880-014-02
|
Facility
|
OP
|
$41,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192965
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,172.16 |
| Max. Negotiated Rate |
$39,994.24 |
| Rate for Payer: Aetna Commercial |
$39,124.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37,385.92
|
| Rate for Payer: Aetna Managed Medicare |
$12,172.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,256.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,736.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,866.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,040.16
|
| Rate for Payer: Cash Price |
$12,540.00
|
| Rate for Payer: Cigna Commercial |
$39,994.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,327.60
|
| Rate for Payer: Health EOS Commercial |
$38,690.08
|
| Rate for Payer: HFN Commercial |
$39,994.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,604.00
|
| Rate for Payer: Multiplan Commercial |
$34,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$26,083.20
|
| Rate for Payer: Preferred Network Access Commercial |
$39,994.24
|
| Rate for Payer: Quartz Beloit One Network |
$21,301.28
|
| Rate for Payer: Quartz Commercial |
$28,256.80
|
| Rate for Payer: Quartz Medicare Advantage |
$26,083.20
|
| Rate for Payer: The Alliance Commercial |
$21,736.00
|
| Rate for Payer: WEA Trust Commercial |
$23,909.60
|
| Rate for Payer: WPS Commercial |
$32,198.54
|
|
|
FEMORAL ROTATING HINGE NEXGEN CEMENTED RT SZ D 00-5880-014-02
|
Facility
|
IP
|
$41,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192965
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,301.28 |
| Max. Negotiated Rate |
$39,994.24 |
| Rate for Payer: Aetna Commercial |
$39,124.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37,385.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,040.16
|
| Rate for Payer: Cash Price |
$12,540.00
|
| Rate for Payer: Cigna Commercial |
$39,994.24
|
| Rate for Payer: Health EOS Commercial |
$38,690.08
|
| Rate for Payer: HFN Commercial |
$39,994.24
|
| Rate for Payer: Multiplan Commercial |
$34,777.60
|
| Rate for Payer: Preferred Network Access Commercial |
$39,994.24
|
| Rate for Payer: Quartz Beloit One Network |
$21,301.28
|
| Rate for Payer: Quartz Commercial |
$26,083.20
|
| Rate for Payer: WEA Trust Commercial |
$23,909.60
|
| Rate for Payer: WPS Commercial |
$32,198.54
|
|
