|
FEMORAL HEAD COCR 28MM +0 802202802
|
Facility
|
IP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5895652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,059.96 |
| Max. Negotiated Rate |
$3,867.68 |
| Rate for Payer: Aetna Commercial |
$3,783.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,615.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,228.12
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$3,867.68
|
| Rate for Payer: Health EOS Commercial |
$3,741.56
|
| Rate for Payer: HFN Commercial |
$3,867.68
|
| Rate for Payer: Multiplan Commercial |
$3,363.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,522.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,867.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,059.96
|
| Rate for Payer: Quartz Commercial |
$2,522.40
|
| Rate for Payer: WEA Trust Commercial |
$2,312.20
|
| Rate for Payer: WPS Commercial |
$3,113.90
|
|
|
FEMORAL HEAD COCR 28MM +0 802202802
|
Facility
|
OP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5895652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,177.12 |
| Max. Negotiated Rate |
$16,816.00 |
| Rate for Payer: Aetna Commercial |
$3,783.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,615.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,177.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,732.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,102.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,017.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,228.12
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$3,867.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,352.56
|
| Rate for Payer: Health EOS Commercial |
$3,741.56
|
| Rate for Payer: HFN Commercial |
$3,867.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,153.00
|
| Rate for Payer: Multiplan Commercial |
$3,363.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,522.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,867.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,059.96
|
| Rate for Payer: Quartz Commercial |
$2,732.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,522.40
|
| Rate for Payer: The Alliance Commercial |
$16,816.00
|
| Rate for Payer: WEA Trust Commercial |
$2,312.20
|
| Rate for Payer: WPS Commercial |
$3,113.90
|
|
|
FEMORAL HEAD COCR 28MM -3.5 802202801
|
Facility
|
IP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,059.96 |
| Max. Negotiated Rate |
$3,867.68 |
| Rate for Payer: Aetna Commercial |
$3,783.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,615.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,228.12
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$3,867.68
|
| Rate for Payer: Health EOS Commercial |
$3,741.56
|
| Rate for Payer: HFN Commercial |
$3,867.68
|
| Rate for Payer: Multiplan Commercial |
$3,363.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,522.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,867.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,059.96
|
| Rate for Payer: Quartz Commercial |
$2,522.40
|
| Rate for Payer: WEA Trust Commercial |
$2,312.20
|
| Rate for Payer: WPS Commercial |
$3,113.90
|
|
|
FEMORAL HEAD COCR 28MM -3.5 802202801
|
Facility
|
OP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5861628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,177.12 |
| Max. Negotiated Rate |
$16,816.00 |
| Rate for Payer: Aetna Commercial |
$3,783.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,615.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,177.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,732.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,102.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,017.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,228.12
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$3,867.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,352.56
|
| Rate for Payer: Health EOS Commercial |
$3,741.56
|
| Rate for Payer: HFN Commercial |
$3,867.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,153.00
|
| Rate for Payer: Multiplan Commercial |
$3,363.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,522.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,867.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,059.96
|
| Rate for Payer: Quartz Commercial |
$2,732.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,522.40
|
| Rate for Payer: The Alliance Commercial |
$16,816.00
|
| Rate for Payer: WEA Trust Commercial |
$2,312.20
|
| Rate for Payer: WPS Commercial |
$3,113.90
|
|
|
FEMORAL HEAD COCR 28MM +3.5 802202803
|
Facility
|
OP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5810137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,177.12 |
| Max. Negotiated Rate |
$16,816.00 |
| Rate for Payer: Aetna Commercial |
$3,783.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,615.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,177.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,732.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,102.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,017.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,228.12
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$3,867.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,352.56
|
| Rate for Payer: Health EOS Commercial |
$3,741.56
|
| Rate for Payer: HFN Commercial |
$3,867.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,153.00
|
| Rate for Payer: Multiplan Commercial |
$3,363.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,522.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,867.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,059.96
|
| Rate for Payer: Quartz Commercial |
$2,732.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,522.40
|
| Rate for Payer: The Alliance Commercial |
$16,816.00
|
| Rate for Payer: WEA Trust Commercial |
$2,312.20
|
| Rate for Payer: WPS Commercial |
$3,113.90
|
|
|
FEMORAL HEAD COCR 28MM +3.5 802202803
|
Facility
|
IP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5810137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,059.96 |
| Max. Negotiated Rate |
$3,867.68 |
| Rate for Payer: Aetna Commercial |
$3,783.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,615.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,228.12
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$3,867.68
|
| Rate for Payer: Health EOS Commercial |
$3,741.56
|
| Rate for Payer: HFN Commercial |
$3,867.68
|
| Rate for Payer: Multiplan Commercial |
$3,363.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,522.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,867.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,059.96
|
| Rate for Payer: Quartz Commercial |
$2,522.40
|
| Rate for Payer: WEA Trust Commercial |
$2,312.20
|
| Rate for Payer: WPS Commercial |
$3,113.90
|
|
|
FEMORAL HEAD COCR 28MM +7.0 802202804
|
Facility
|
IP
|
$3,924.28
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,922.90 |
| Max. Negotiated Rate |
$3,610.34 |
| Rate for Payer: Aetna Commercial |
$3,531.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,374.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,079.87
|
| Rate for Payer: Cash Price |
$1,177.28
|
| Rate for Payer: Cigna Commercial |
$3,610.34
|
| Rate for Payer: Health EOS Commercial |
$3,492.61
|
| Rate for Payer: HFN Commercial |
$3,610.34
|
| Rate for Payer: Multiplan Commercial |
$3,139.42
|
| Rate for Payer: NAPHCARE Commercial |
$2,354.57
|
| Rate for Payer: Preferred Network Access Commercial |
$3,610.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,922.90
|
| Rate for Payer: Quartz Commercial |
$2,354.57
|
| Rate for Payer: WEA Trust Commercial |
$2,158.35
|
| Rate for Payer: WPS Commercial |
$2,906.71
|
|
|
FEMORAL HEAD COCR 28MM +7.0 802202804
|
Facility
|
OP
|
$3,924.28
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,098.80 |
| Max. Negotiated Rate |
$15,697.12 |
| Rate for Payer: Aetna Commercial |
$3,531.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,374.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,098.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,550.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,962.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,883.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,079.87
|
| Rate for Payer: Cash Price |
$1,177.28
|
| Rate for Payer: Cigna Commercial |
$3,610.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,196.03
|
| Rate for Payer: Health EOS Commercial |
$3,492.61
|
| Rate for Payer: HFN Commercial |
$3,610.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,943.21
|
| Rate for Payer: Multiplan Commercial |
$3,139.42
|
| Rate for Payer: NAPHCARE Commercial |
$2,354.57
|
| Rate for Payer: Preferred Network Access Commercial |
$3,610.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,922.90
|
| Rate for Payer: Quartz Commercial |
$2,550.78
|
| Rate for Payer: Quartz Medicare Advantage |
$2,354.57
|
| Rate for Payer: The Alliance Commercial |
$15,697.12
|
| Rate for Payer: WEA Trust Commercial |
$2,158.35
|
| Rate for Payer: WPS Commercial |
$2,906.71
|
|
|
FEMORAL HEAD LFIT 36MM +2.5MM
|
Facility
|
OP
|
$5,492.00
|
|
| Hospital Charge Code |
3072476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,537.76 |
| Max. Negotiated Rate |
$21,968.00 |
| Rate for Payer: Aetna Commercial |
$4,942.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,723.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,537.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,569.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,746.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,636.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,910.76
|
| Rate for Payer: Cash Price |
$1,647.60
|
| Rate for Payer: Cigna Commercial |
$5,052.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,073.32
|
| Rate for Payer: Health EOS Commercial |
$4,887.88
|
| Rate for Payer: HFN Commercial |
$5,052.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,119.00
|
| Rate for Payer: Multiplan Commercial |
$4,393.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,295.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,052.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,691.08
|
| Rate for Payer: Quartz Commercial |
$3,569.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,295.20
|
| Rate for Payer: The Alliance Commercial |
$21,968.00
|
| Rate for Payer: WEA Trust Commercial |
$3,020.60
|
| Rate for Payer: WPS Commercial |
$4,067.92
|
|
|
FEMORAL HEAD LFIT 36MM +2.5MM
|
Facility
|
IP
|
$5,492.00
|
|
| Hospital Charge Code |
3072476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,691.08 |
| Max. Negotiated Rate |
$5,052.64 |
| Rate for Payer: Aetna Commercial |
$4,942.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,723.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,910.76
|
| Rate for Payer: Cash Price |
$1,647.60
|
| Rate for Payer: Cigna Commercial |
$5,052.64
|
| Rate for Payer: Health EOS Commercial |
$4,887.88
|
| Rate for Payer: HFN Commercial |
$5,052.64
|
| Rate for Payer: Multiplan Commercial |
$4,393.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,295.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,052.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,691.08
|
| Rate for Payer: Quartz Commercial |
$3,295.20
|
| Rate for Payer: WEA Trust Commercial |
$3,020.60
|
| Rate for Payer: WPS Commercial |
$4,067.92
|
|
|
FEMORAL HEAD LFIT 36MM 3.5 OFFSET 06-3605
|
Facility
|
OP
|
$11,045.00
|
|
| Hospital Charge Code |
2966086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,092.60 |
| Max. Negotiated Rate |
$44,180.00 |
| Rate for Payer: Aetna Commercial |
$9,940.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,498.70
|
| Rate for Payer: Aetna Managed Medicare |
$3,092.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,179.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,522.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,301.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,853.85
|
| Rate for Payer: Cash Price |
$3,313.50
|
| Rate for Payer: Cigna Commercial |
$10,161.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,180.78
|
| Rate for Payer: Health EOS Commercial |
$9,830.05
|
| Rate for Payer: HFN Commercial |
$10,161.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,283.75
|
| Rate for Payer: Multiplan Commercial |
$8,836.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,627.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,161.40
|
| Rate for Payer: Quartz Beloit One Network |
$5,412.05
|
| Rate for Payer: Quartz Commercial |
$7,179.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,627.00
|
| Rate for Payer: The Alliance Commercial |
$44,180.00
|
| Rate for Payer: WEA Trust Commercial |
$6,074.75
|
| Rate for Payer: WPS Commercial |
$8,181.03
|
|
|
FEMORAL HEAD LFIT 36MM 3.5 OFFSET 06-3605
|
Facility
|
IP
|
$11,045.00
|
|
| Hospital Charge Code |
2966086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,412.05 |
| Max. Negotiated Rate |
$10,161.40 |
| Rate for Payer: Aetna Commercial |
$9,940.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,498.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,853.85
|
| Rate for Payer: Cash Price |
$3,313.50
|
| Rate for Payer: Cigna Commercial |
$10,161.40
|
| Rate for Payer: Health EOS Commercial |
$9,830.05
|
| Rate for Payer: HFN Commercial |
$10,161.40
|
| Rate for Payer: Multiplan Commercial |
$8,836.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,627.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,161.40
|
| Rate for Payer: Quartz Beloit One Network |
$5,412.05
|
| Rate for Payer: Quartz Commercial |
$6,627.00
|
| Rate for Payer: WEA Trust Commercial |
$6,074.75
|
| Rate for Payer: WPS Commercial |
$8,181.03
|
|
|
FEMORAL HEAD LFIT V40 36MM +0 6260-9-136
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4520308
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 36MM +0 6260-9-136
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4520308
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 36MM +10 6260-9-336
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
3487504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 36MM +10 6260-9-336
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
3487504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 36MM +5 6260-9-236
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4167700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 36MM +5 6260-9-236
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4167700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 40MM +0 6260-9-140
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4520142
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 40MM +0 6260-9-140
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4520142
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 40MM +12 6260-9-440
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4520024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 40MM +12 6260-9-440
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4520024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 40MM +4 6260-9-240
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4028636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 40MM +4 6260-9-240
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4028636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
FEMORAL HEAD LFIT V40 40MM +8 6260-9-340
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
3949331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
