|
FEMORAL HEAD BIOLOX CERAMIC 32MM +5.0 12/14 1365-32-320
|
Facility
|
IP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.17 |
| Max. Negotiated Rate |
$5,090.36 |
| Rate for Payer: Aetna Commercial |
$4,979.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.49
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,090.36
|
| Rate for Payer: Health EOS Commercial |
$4,924.37
|
| Rate for Payer: HFN Commercial |
$5,090.36
|
| Rate for Payer: Multiplan Commercial |
$4,426.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.17
|
| Rate for Payer: Quartz Commercial |
$3,319.80
|
| Rate for Payer: WEA Trust Commercial |
$3,043.15
|
| Rate for Payer: WPS Commercial |
$4,098.29
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 32MM +5.0 12/14 1365-32-320
|
Facility
|
OP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,549.24 |
| Max. Negotiated Rate |
$22,132.00 |
| Rate for Payer: Aetna Commercial |
$4,979.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,549.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,596.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,766.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,655.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.49
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,090.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,096.27
|
| Rate for Payer: Health EOS Commercial |
$4,924.37
|
| Rate for Payer: HFN Commercial |
$5,090.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,149.75
|
| Rate for Payer: Multiplan Commercial |
$4,426.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.17
|
| Rate for Payer: Quartz Commercial |
$3,596.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,319.80
|
| Rate for Payer: The Alliance Commercial |
$22,132.00
|
| Rate for Payer: WEA Trust Commercial |
$3,043.15
|
| Rate for Payer: WPS Commercial |
$4,098.29
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +12 12/14 1365-36-340
|
Facility
|
IP
|
$6,064.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,971.36 |
| Max. Negotiated Rate |
$5,578.88 |
| Rate for Payer: Aetna Commercial |
$5,457.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,215.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,213.92
|
| Rate for Payer: Cash Price |
$1,819.20
|
| Rate for Payer: Cigna Commercial |
$5,578.88
|
| Rate for Payer: Health EOS Commercial |
$5,396.96
|
| Rate for Payer: HFN Commercial |
$5,578.88
|
| Rate for Payer: Multiplan Commercial |
$4,851.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,638.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,578.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,971.36
|
| Rate for Payer: Quartz Commercial |
$3,638.40
|
| Rate for Payer: WEA Trust Commercial |
$3,335.20
|
| Rate for Payer: WPS Commercial |
$4,491.60
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +12 12/14 1365-36-340
|
Facility
|
OP
|
$6,064.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,697.92 |
| Max. Negotiated Rate |
$24,256.00 |
| Rate for Payer: Aetna Commercial |
$5,457.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,215.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,697.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,941.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,032.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,910.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,213.92
|
| Rate for Payer: Cash Price |
$1,819.20
|
| Rate for Payer: Cigna Commercial |
$5,578.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,393.41
|
| Rate for Payer: Health EOS Commercial |
$5,396.96
|
| Rate for Payer: HFN Commercial |
$5,578.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,548.00
|
| Rate for Payer: Multiplan Commercial |
$4,851.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,638.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,578.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,971.36
|
| Rate for Payer: Quartz Commercial |
$3,941.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,638.40
|
| Rate for Payer: The Alliance Commercial |
$24,256.00
|
| Rate for Payer: WEA Trust Commercial |
$3,335.20
|
| Rate for Payer: WPS Commercial |
$4,491.60
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +1.5 12/14 1365-36-310
|
Facility
|
IP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,814.56 |
| Max. Negotiated Rate |
$5,284.48 |
| Rate for Payer: Aetna Commercial |
$5,169.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,939.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,044.32
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,284.48
|
| Rate for Payer: Health EOS Commercial |
$5,112.16
|
| Rate for Payer: HFN Commercial |
$5,284.48
|
| Rate for Payer: Multiplan Commercial |
$4,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,284.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,814.56
|
| Rate for Payer: Quartz Commercial |
$3,446.40
|
| Rate for Payer: WEA Trust Commercial |
$3,159.20
|
| Rate for Payer: WPS Commercial |
$4,254.58
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +1.5 12/14 1365-36-310
|
Facility
|
OP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,608.32 |
| Max. Negotiated Rate |
$22,976.00 |
| Rate for Payer: Aetna Commercial |
$5,169.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,939.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,608.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,733.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,872.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,757.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,044.32
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,284.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,214.34
|
| Rate for Payer: Health EOS Commercial |
$5,112.16
|
| Rate for Payer: HFN Commercial |
$5,284.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,308.00
|
| Rate for Payer: Multiplan Commercial |
$4,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,284.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,814.56
|
| Rate for Payer: Quartz Commercial |
$3,733.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,446.40
|
| Rate for Payer: The Alliance Commercial |
$22,976.00
|
| Rate for Payer: WEA Trust Commercial |
$3,159.20
|
| Rate for Payer: WPS Commercial |
$4,254.58
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +5 12/14 1365-36-320
|
Facility
|
OP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,608.32 |
| Max. Negotiated Rate |
$22,976.00 |
| Rate for Payer: Aetna Commercial |
$5,169.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,939.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,608.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,733.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,872.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,757.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,044.32
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,284.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,214.34
|
| Rate for Payer: Health EOS Commercial |
$5,112.16
|
| Rate for Payer: HFN Commercial |
$5,284.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,308.00
|
| Rate for Payer: Multiplan Commercial |
$4,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,284.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,814.56
|
| Rate for Payer: Quartz Commercial |
$3,733.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,446.40
|
| Rate for Payer: The Alliance Commercial |
$22,976.00
|
| Rate for Payer: WEA Trust Commercial |
$3,159.20
|
| Rate for Payer: WPS Commercial |
$4,254.58
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +5 12/14 1365-36-320
|
Facility
|
IP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459464
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,814.56 |
| Max. Negotiated Rate |
$5,284.48 |
| Rate for Payer: Aetna Commercial |
$5,169.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,939.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,044.32
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,284.48
|
| Rate for Payer: Health EOS Commercial |
$5,112.16
|
| Rate for Payer: HFN Commercial |
$5,284.48
|
| Rate for Payer: Multiplan Commercial |
$4,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,284.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,814.56
|
| Rate for Payer: Quartz Commercial |
$3,446.40
|
| Rate for Payer: WEA Trust Commercial |
$3,159.20
|
| Rate for Payer: WPS Commercial |
$4,254.58
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +8.5 12/14 1365-36-330
|
Facility
|
IP
|
$5,320.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563290
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,606.80 |
| Max. Negotiated Rate |
$4,894.40 |
| Rate for Payer: Aetna Commercial |
$4,788.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,575.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,819.60
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cigna Commercial |
$4,894.40
|
| Rate for Payer: Health EOS Commercial |
$4,734.80
|
| Rate for Payer: HFN Commercial |
$4,894.40
|
| Rate for Payer: Multiplan Commercial |
$4,256.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,894.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,606.80
|
| Rate for Payer: Quartz Commercial |
$3,192.00
|
| Rate for Payer: WEA Trust Commercial |
$2,926.00
|
| Rate for Payer: WPS Commercial |
$3,940.52
|
|
|
FEMORAL HEAD BIOLOX CERAMIC 36MM +8.5 12/14 1365-36-330
|
Facility
|
OP
|
$5,320.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563290
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,489.60 |
| Max. Negotiated Rate |
$21,280.00 |
| Rate for Payer: Aetna Commercial |
$4,788.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,575.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,489.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,458.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,660.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,553.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,819.60
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cigna Commercial |
$4,894.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,977.07
|
| Rate for Payer: Health EOS Commercial |
$4,734.80
|
| Rate for Payer: HFN Commercial |
$4,894.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,990.00
|
| Rate for Payer: Multiplan Commercial |
$4,256.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,894.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,606.80
|
| Rate for Payer: Quartz Commercial |
$3,458.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,192.00
|
| Rate for Payer: The Alliance Commercial |
$21,280.00
|
| Rate for Payer: WEA Trust Commercial |
$2,926.00
|
| Rate for Payer: WPS Commercial |
$3,940.52
|
|
|
FEMORAL HEAD BIOLOX CERAMIC REVISION 36MM +5 12/14 1365-36-720
|
Facility
|
IP
|
$5,397.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5767774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,644.53 |
| Max. Negotiated Rate |
$4,965.24 |
| Rate for Payer: Aetna Commercial |
$4,857.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,641.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,860.41
|
| Rate for Payer: Cash Price |
$1,619.10
|
| Rate for Payer: Cigna Commercial |
$4,965.24
|
| Rate for Payer: Health EOS Commercial |
$4,803.33
|
| Rate for Payer: HFN Commercial |
$4,965.24
|
| Rate for Payer: Multiplan Commercial |
$4,317.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,965.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,644.53
|
| Rate for Payer: Quartz Commercial |
$3,238.20
|
| Rate for Payer: WEA Trust Commercial |
$2,968.35
|
| Rate for Payer: WPS Commercial |
$3,997.56
|
|
|
FEMORAL HEAD BIOLOX CERAMIC REVISION 36MM +5 12/14 1365-36-720
|
Facility
|
OP
|
$5,397.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5767774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,511.16 |
| Max. Negotiated Rate |
$21,588.00 |
| Rate for Payer: Aetna Commercial |
$4,857.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,641.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,511.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,508.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,698.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,590.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,860.41
|
| Rate for Payer: Cash Price |
$1,619.10
|
| Rate for Payer: Cigna Commercial |
$4,965.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,020.16
|
| Rate for Payer: Health EOS Commercial |
$4,803.33
|
| Rate for Payer: HFN Commercial |
$4,965.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,047.75
|
| Rate for Payer: Multiplan Commercial |
$4,317.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,965.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,644.53
|
| Rate for Payer: Quartz Commercial |
$3,508.05
|
| Rate for Payer: Quartz Medicare Advantage |
$3,238.20
|
| Rate for Payer: The Alliance Commercial |
$21,588.00
|
| Rate for Payer: WEA Trust Commercial |
$2,968.35
|
| Rate for Payer: WPS Commercial |
$3,997.56
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 28MM +3MM 650-1157
|
Facility
|
OP
|
$5,255.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.40 |
| Max. Negotiated Rate |
$21,020.00 |
| Rate for Payer: Aetna Commercial |
$4,729.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,519.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,471.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,415.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,627.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,522.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.15
|
| Rate for Payer: Cash Price |
$1,576.50
|
| Rate for Payer: Cigna Commercial |
$4,834.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,940.70
|
| Rate for Payer: Health EOS Commercial |
$4,676.95
|
| Rate for Payer: HFN Commercial |
$4,834.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,941.25
|
| Rate for Payer: Multiplan Commercial |
$4,204.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,153.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,834.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,574.95
|
| Rate for Payer: Quartz Commercial |
$3,415.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3,153.00
|
| Rate for Payer: The Alliance Commercial |
$21,020.00
|
| Rate for Payer: WEA Trust Commercial |
$2,890.25
|
| Rate for Payer: WPS Commercial |
$3,892.38
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 28MM +3MM 650-1157
|
Facility
|
IP
|
$5,255.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,574.95 |
| Max. Negotiated Rate |
$4,834.60 |
| Rate for Payer: Aetna Commercial |
$4,729.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,519.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.15
|
| Rate for Payer: Cash Price |
$1,576.50
|
| Rate for Payer: Cigna Commercial |
$4,834.60
|
| Rate for Payer: Health EOS Commercial |
$4,676.95
|
| Rate for Payer: HFN Commercial |
$4,834.60
|
| Rate for Payer: Multiplan Commercial |
$4,204.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,153.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,834.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,574.95
|
| Rate for Payer: Quartz Commercial |
$3,153.00
|
| Rate for Payer: WEA Trust Commercial |
$2,890.25
|
| Rate for Payer: WPS Commercial |
$3,892.38
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 32MM +0MM 00-8775-032-02
|
Facility
|
IP
|
$7,948.00
|
|
| Hospital Charge Code |
4230457
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,894.52 |
| Max. Negotiated Rate |
$7,312.16 |
| Rate for Payer: Aetna Commercial |
$7,153.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,835.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,212.44
|
| Rate for Payer: Cash Price |
$2,384.40
|
| Rate for Payer: Cigna Commercial |
$7,312.16
|
| Rate for Payer: Health EOS Commercial |
$7,073.72
|
| Rate for Payer: HFN Commercial |
$7,312.16
|
| Rate for Payer: Multiplan Commercial |
$6,358.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,768.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,312.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,894.52
|
| Rate for Payer: Quartz Commercial |
$4,768.80
|
| Rate for Payer: WEA Trust Commercial |
$4,371.40
|
| Rate for Payer: WPS Commercial |
$5,887.08
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 32MM +0MM 00-8775-032-02
|
Facility
|
OP
|
$7,948.00
|
|
| Hospital Charge Code |
4230457
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,225.44 |
| Max. Negotiated Rate |
$31,792.00 |
| Rate for Payer: Aetna Commercial |
$7,153.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,835.28
|
| Rate for Payer: Aetna Managed Medicare |
$2,225.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,166.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,974.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,815.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,212.44
|
| Rate for Payer: Cash Price |
$2,384.40
|
| Rate for Payer: Cigna Commercial |
$7,312.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,447.70
|
| Rate for Payer: Health EOS Commercial |
$7,073.72
|
| Rate for Payer: HFN Commercial |
$7,312.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,961.00
|
| Rate for Payer: Multiplan Commercial |
$6,358.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,768.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,312.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,894.52
|
| Rate for Payer: Quartz Commercial |
$5,166.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,768.80
|
| Rate for Payer: The Alliance Commercial |
$31,792.00
|
| Rate for Payer: WEA Trust Commercial |
$4,371.40
|
| Rate for Payer: WPS Commercial |
$5,887.08
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 32MM -3.5MM 00-8775-032-01
|
Facility
|
OP
|
$8,296.00
|
|
| Hospital Charge Code |
2967478
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,322.88 |
| Max. Negotiated Rate |
$33,184.00 |
| Rate for Payer: Aetna Commercial |
$7,466.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,134.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,322.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,392.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,148.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,982.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,396.88
|
| Rate for Payer: Cash Price |
$2,488.80
|
| Rate for Payer: Cigna Commercial |
$7,632.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,642.44
|
| Rate for Payer: Health EOS Commercial |
$7,383.44
|
| Rate for Payer: HFN Commercial |
$7,632.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,222.00
|
| Rate for Payer: Multiplan Commercial |
$6,636.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,977.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,632.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,065.04
|
| Rate for Payer: Quartz Commercial |
$5,392.40
|
| Rate for Payer: Quartz Medicare Advantage |
$4,977.60
|
| Rate for Payer: The Alliance Commercial |
$33,184.00
|
| Rate for Payer: WEA Trust Commercial |
$4,562.80
|
| Rate for Payer: WPS Commercial |
$6,144.85
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 32MM -3.5MM 00-8775-032-01
|
Facility
|
IP
|
$8,296.00
|
|
| Hospital Charge Code |
2967478
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,065.04 |
| Max. Negotiated Rate |
$7,632.32 |
| Rate for Payer: Aetna Commercial |
$7,466.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,134.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,396.88
|
| Rate for Payer: Cash Price |
$2,488.80
|
| Rate for Payer: Cigna Commercial |
$7,632.32
|
| Rate for Payer: Health EOS Commercial |
$7,383.44
|
| Rate for Payer: HFN Commercial |
$7,632.32
|
| Rate for Payer: Multiplan Commercial |
$6,636.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,977.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,632.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,065.04
|
| Rate for Payer: Quartz Commercial |
$4,977.60
|
| Rate for Payer: WEA Trust Commercial |
$4,562.80
|
| Rate for Payer: WPS Commercial |
$6,144.85
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 32MM +3.5MM 00-8775-032-03
|
Facility
|
OP
|
$7,653.00
|
|
| Hospital Charge Code |
4230458
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.84 |
| Max. Negotiated Rate |
$30,612.00 |
| Rate for Payer: Aetna Commercial |
$6,887.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,581.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,142.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,974.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,826.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,673.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,056.09
|
| Rate for Payer: Cash Price |
$2,295.90
|
| Rate for Payer: Cigna Commercial |
$7,040.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,282.62
|
| Rate for Payer: Health EOS Commercial |
$6,811.17
|
| Rate for Payer: HFN Commercial |
$7,040.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,739.75
|
| Rate for Payer: Multiplan Commercial |
$6,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,591.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,040.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,749.97
|
| Rate for Payer: Quartz Commercial |
$4,974.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,591.80
|
| Rate for Payer: The Alliance Commercial |
$30,612.00
|
| Rate for Payer: WEA Trust Commercial |
$4,209.15
|
| Rate for Payer: WPS Commercial |
$5,668.58
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 32MM +3.5MM 00-8775-032-03
|
Facility
|
IP
|
$7,653.00
|
|
| Hospital Charge Code |
4230458
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,749.97 |
| Max. Negotiated Rate |
$7,040.76 |
| Rate for Payer: Aetna Commercial |
$6,887.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,581.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,056.09
|
| Rate for Payer: Cash Price |
$2,295.90
|
| Rate for Payer: Cigna Commercial |
$7,040.76
|
| Rate for Payer: Health EOS Commercial |
$6,811.17
|
| Rate for Payer: HFN Commercial |
$7,040.76
|
| Rate for Payer: Multiplan Commercial |
$6,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,591.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,040.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,749.97
|
| Rate for Payer: Quartz Commercial |
$4,591.80
|
| Rate for Payer: WEA Trust Commercial |
$4,209.15
|
| Rate for Payer: WPS Commercial |
$5,668.58
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 32MM +7MM 00-8775-032-04
|
Facility
|
IP
|
$7,653.00
|
|
| Hospital Charge Code |
4230459
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,749.97 |
| Max. Negotiated Rate |
$7,040.76 |
| Rate for Payer: Aetna Commercial |
$6,887.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,581.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,056.09
|
| Rate for Payer: Cash Price |
$2,295.90
|
| Rate for Payer: Cigna Commercial |
$7,040.76
|
| Rate for Payer: Health EOS Commercial |
$6,811.17
|
| Rate for Payer: HFN Commercial |
$7,040.76
|
| Rate for Payer: Multiplan Commercial |
$6,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,591.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,040.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,749.97
|
| Rate for Payer: Quartz Commercial |
$4,591.80
|
| Rate for Payer: WEA Trust Commercial |
$4,209.15
|
| Rate for Payer: WPS Commercial |
$5,668.58
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 32MM +7MM 00-8775-032-04
|
Facility
|
OP
|
$7,653.00
|
|
| Hospital Charge Code |
4230459
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.84 |
| Max. Negotiated Rate |
$30,612.00 |
| Rate for Payer: Aetna Commercial |
$6,887.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,581.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,142.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,974.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,826.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,673.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,056.09
|
| Rate for Payer: Cash Price |
$2,295.90
|
| Rate for Payer: Cigna Commercial |
$7,040.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,282.62
|
| Rate for Payer: Health EOS Commercial |
$6,811.17
|
| Rate for Payer: HFN Commercial |
$7,040.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,739.75
|
| Rate for Payer: Multiplan Commercial |
$6,122.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,591.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,040.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,749.97
|
| Rate for Payer: Quartz Commercial |
$4,974.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,591.80
|
| Rate for Payer: The Alliance Commercial |
$30,612.00
|
| Rate for Payer: WEA Trust Commercial |
$4,209.15
|
| Rate for Payer: WPS Commercial |
$5,668.58
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 36MM +0MM 00-8775-036-02
|
Facility
|
OP
|
$7,948.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,225.44 |
| Max. Negotiated Rate |
$31,792.00 |
| Rate for Payer: Aetna Commercial |
$7,153.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,835.28
|
| Rate for Payer: Aetna Managed Medicare |
$2,225.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,166.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,974.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,815.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,212.44
|
| Rate for Payer: Cash Price |
$2,384.40
|
| Rate for Payer: Cigna Commercial |
$7,312.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,447.70
|
| Rate for Payer: Health EOS Commercial |
$7,073.72
|
| Rate for Payer: HFN Commercial |
$7,312.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,961.00
|
| Rate for Payer: Multiplan Commercial |
$6,358.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,768.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,312.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,894.52
|
| Rate for Payer: Quartz Commercial |
$5,166.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,768.80
|
| Rate for Payer: The Alliance Commercial |
$31,792.00
|
| Rate for Payer: WEA Trust Commercial |
$4,371.40
|
| Rate for Payer: WPS Commercial |
$5,887.08
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 36MM +0MM 00-8775-036-02
|
Facility
|
IP
|
$7,948.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,894.52 |
| Max. Negotiated Rate |
$7,312.16 |
| Rate for Payer: Aetna Commercial |
$7,153.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,835.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,212.44
|
| Rate for Payer: Cash Price |
$2,384.40
|
| Rate for Payer: Cigna Commercial |
$7,312.16
|
| Rate for Payer: Health EOS Commercial |
$7,073.72
|
| Rate for Payer: HFN Commercial |
$7,312.16
|
| Rate for Payer: Multiplan Commercial |
$6,358.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,768.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,312.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,894.52
|
| Rate for Payer: Quartz Commercial |
$4,768.80
|
| Rate for Payer: WEA Trust Commercial |
$4,371.40
|
| Rate for Payer: WPS Commercial |
$5,887.08
|
|
|
FEMORAL HEAD BIOLOX DELTA CERAMIC 36MM +0MM 6570-0-136
|
Facility
|
IP
|
$6,967.00
|
|
| Hospital Charge Code |
3937337
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,413.83 |
| Max. Negotiated Rate |
$6,409.64 |
| Rate for Payer: Aetna Commercial |
$6,270.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,991.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,692.51
|
| Rate for Payer: Cash Price |
$2,090.10
|
| Rate for Payer: Cigna Commercial |
$6,409.64
|
| Rate for Payer: Health EOS Commercial |
$6,200.63
|
| Rate for Payer: HFN Commercial |
$6,409.64
|
| Rate for Payer: Multiplan Commercial |
$5,573.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,180.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,409.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,413.83
|
| Rate for Payer: Quartz Commercial |
$4,180.20
|
| Rate for Payer: WEA Trust Commercial |
$3,831.85
|
| Rate for Payer: WPS Commercial |
$5,160.46
|
|
