|
FEMORAL HEAD LFIT V40 40MM +8 6260-9-340
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
3949331
|
|
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 44MM -4 6260-9-044
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4508748
|
|
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 44MM -4 6260-9-044
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4508748
|
|
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 44MM +4 6260-9-244
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4594901
|
|
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 44MM +4 6260-9-244
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4594901
|
|
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 M-SPEC METAL 36MM +12 12/14 1365-54-000
|
Facility
|
IP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5597547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.32 |
| Max. Negotiated Rate |
$3,834.56 |
| Rate for Payer: Aetna Commercial |
$3,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.04
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,834.56
|
| Rate for Payer: Health EOS Commercial |
$3,709.52
|
| Rate for Payer: HFN Commercial |
$3,834.56
|
| Rate for Payer: Multiplan Commercial |
$3,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.32
|
| Rate for Payer: Quartz Commercial |
$2,500.80
|
| Rate for Payer: WEA Trust Commercial |
$2,292.40
|
| Rate for Payer: WPS Commercial |
$3,087.24
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +12 12/14 1365-54-000
|
Facility
|
OP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5597547
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.04 |
| Max. Negotiated Rate |
$16,672.00 |
| Rate for Payer: Aetna Commercial |
$3,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,709.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,084.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,000.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.04
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,834.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,332.41
|
| Rate for Payer: Health EOS Commercial |
$3,709.52
|
| Rate for Payer: HFN Commercial |
$3,834.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,126.00
|
| Rate for Payer: Multiplan Commercial |
$3,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.32
|
| Rate for Payer: Quartz Commercial |
$2,709.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,500.80
|
| Rate for Payer: The Alliance Commercial |
$16,672.00
|
| Rate for Payer: WEA Trust Commercial |
$2,292.40
|
| Rate for Payer: WPS Commercial |
$3,087.24
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +1.5 12/14 1365-51-000
|
Facility
|
IP
|
$5,170.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,533.30 |
| Max. Negotiated Rate |
$4,756.40 |
| Rate for Payer: Aetna Commercial |
$4,653.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,446.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,740.10
|
| Rate for Payer: Cash Price |
$1,551.00
|
| Rate for Payer: Cigna Commercial |
$4,756.40
|
| Rate for Payer: Health EOS Commercial |
$4,601.30
|
| Rate for Payer: HFN Commercial |
$4,756.40
|
| Rate for Payer: Multiplan Commercial |
$4,136.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,756.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,533.30
|
| Rate for Payer: Quartz Commercial |
$3,102.00
|
| Rate for Payer: WEA Trust Commercial |
$2,843.50
|
| Rate for Payer: WPS Commercial |
$3,829.42
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +1.5 12/14 1365-51-000
|
Facility
|
OP
|
$5,170.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,447.60 |
| Max. Negotiated Rate |
$20,680.00 |
| Rate for Payer: Aetna Commercial |
$4,653.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,446.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,447.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,360.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,585.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,481.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,740.10
|
| Rate for Payer: Cash Price |
$1,551.00
|
| Rate for Payer: Cigna Commercial |
$4,756.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,893.13
|
| Rate for Payer: Health EOS Commercial |
$4,601.30
|
| Rate for Payer: HFN Commercial |
$4,756.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,877.50
|
| Rate for Payer: Multiplan Commercial |
$4,136.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,756.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,533.30
|
| Rate for Payer: Quartz Commercial |
$3,360.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,102.00
|
| Rate for Payer: The Alliance Commercial |
$20,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,843.50
|
| Rate for Payer: WPS Commercial |
$3,829.42
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +15.5 12/14 1365-55-000
|
Facility
|
OP
|
$3,706.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6196976
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.68 |
| Max. Negotiated Rate |
$14,824.00 |
| Rate for Payer: Aetna Commercial |
$3,335.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,187.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,037.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,408.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,853.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,778.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,964.18
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cigna Commercial |
$3,409.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,073.88
|
| Rate for Payer: Health EOS Commercial |
$3,298.34
|
| Rate for Payer: HFN Commercial |
$3,409.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,779.50
|
| Rate for Payer: Multiplan Commercial |
$2,964.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,223.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,409.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,815.94
|
| Rate for Payer: Quartz Commercial |
$2,408.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,223.60
|
| Rate for Payer: The Alliance Commercial |
$14,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,038.30
|
| Rate for Payer: WPS Commercial |
$2,745.03
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +15.5 12/14 1365-55-000
|
Facility
|
IP
|
$3,706.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6196976
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,815.94 |
| Max. Negotiated Rate |
$3,409.52 |
| Rate for Payer: Aetna Commercial |
$3,335.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,187.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,964.18
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cigna Commercial |
$3,409.52
|
| Rate for Payer: Health EOS Commercial |
$3,298.34
|
| Rate for Payer: HFN Commercial |
$3,409.52
|
| Rate for Payer: Multiplan Commercial |
$2,964.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,223.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,409.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,815.94
|
| Rate for Payer: Quartz Commercial |
$2,223.60
|
| Rate for Payer: WEA Trust Commercial |
$2,038.30
|
| Rate for Payer: WPS Commercial |
$2,745.03
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM -2 12/14 1365-50-000
|
Facility
|
IP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.32 |
| Max. Negotiated Rate |
$3,834.56 |
| Rate for Payer: Aetna Commercial |
$3,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.04
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,834.56
|
| Rate for Payer: Health EOS Commercial |
$3,709.52
|
| Rate for Payer: HFN Commercial |
$3,834.56
|
| Rate for Payer: Multiplan Commercial |
$3,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.32
|
| Rate for Payer: Quartz Commercial |
$2,500.80
|
| Rate for Payer: WEA Trust Commercial |
$2,292.40
|
| Rate for Payer: WPS Commercial |
$3,087.24
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM -2 12/14 1365-50-000
|
Facility
|
OP
|
$4,168.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.04 |
| Max. Negotiated Rate |
$16,672.00 |
| Rate for Payer: Aetna Commercial |
$3,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,709.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,084.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,000.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.04
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,834.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,332.41
|
| Rate for Payer: Health EOS Commercial |
$3,709.52
|
| Rate for Payer: HFN Commercial |
$3,834.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,126.00
|
| Rate for Payer: Multiplan Commercial |
$3,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.32
|
| Rate for Payer: Quartz Commercial |
$2,709.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,500.80
|
| Rate for Payer: The Alliance Commercial |
$16,672.00
|
| Rate for Payer: WEA Trust Commercial |
$2,292.40
|
| Rate for Payer: WPS Commercial |
$3,087.24
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +5 12/14 1365-52-000
|
Facility
|
IP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.22 |
| Max. Negotiated Rate |
$4,579.76 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$2,986.80
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +5 12/14 1365-52-000
|
Facility
|
OP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.84 |
| Max. Negotiated Rate |
$19,912.00 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,235.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,785.69
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.50
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$3,235.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,986.80
|
| Rate for Payer: The Alliance Commercial |
$19,912.00
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +8.5 12/14 1365-53-000
|
Facility
|
OP
|
$4,787.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563409
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,340.36 |
| Max. Negotiated Rate |
$19,148.00 |
| Rate for Payer: Aetna Commercial |
$4,308.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,116.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,340.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,111.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,393.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,297.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,537.11
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,404.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,678.81
|
| Rate for Payer: Health EOS Commercial |
$4,260.43
|
| Rate for Payer: HFN Commercial |
$4,404.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,590.25
|
| Rate for Payer: Multiplan Commercial |
$3,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,404.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,345.63
|
| Rate for Payer: Quartz Commercial |
$3,111.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,872.20
|
| Rate for Payer: The Alliance Commercial |
$19,148.00
|
| Rate for Payer: WEA Trust Commercial |
$2,632.85
|
| Rate for Payer: WPS Commercial |
$3,545.73
|
|
|
FEMORAL HEAD M-SPEC METAL 36MM +8.5 12/14 1365-53-000
|
Facility
|
IP
|
$4,787.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563409
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,345.63 |
| Max. Negotiated Rate |
$4,404.04 |
| Rate for Payer: Aetna Commercial |
$4,308.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,116.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,537.11
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,404.04
|
| Rate for Payer: Health EOS Commercial |
$4,260.43
|
| Rate for Payer: HFN Commercial |
$4,404.04
|
| Rate for Payer: Multiplan Commercial |
$3,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,404.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,345.63
|
| Rate for Payer: Quartz Commercial |
$2,872.20
|
| Rate for Payer: WEA Trust Commercial |
$2,632.85
|
| Rate for Payer: WPS Commercial |
$3,545.73
|
|
|
FEMORAL HEAD M-SPEC METAL 40MM +12 12/14 1365-08-000
|
Facility
|
OP
|
$5,578.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6198967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.84 |
| Max. Negotiated Rate |
$22,312.00 |
| Rate for Payer: Aetna Commercial |
$5,020.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,797.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,561.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,625.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,789.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,677.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,956.34
|
| Rate for Payer: Cash Price |
$1,673.40
|
| Rate for Payer: Cigna Commercial |
$5,131.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,121.45
|
| Rate for Payer: Health EOS Commercial |
$4,964.42
|
| Rate for Payer: HFN Commercial |
$5,131.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,183.50
|
| Rate for Payer: Multiplan Commercial |
$4,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,346.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,131.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,733.22
|
| Rate for Payer: Quartz Commercial |
$3,625.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,346.80
|
| Rate for Payer: The Alliance Commercial |
$22,312.00
|
| Rate for Payer: WEA Trust Commercial |
$3,067.90
|
| Rate for Payer: WPS Commercial |
$4,131.62
|
|
|
FEMORAL HEAD M-SPEC METAL 40MM +12 12/14 1365-08-000
|
Facility
|
IP
|
$5,578.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6198967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,733.22 |
| Max. Negotiated Rate |
$5,131.76 |
| Rate for Payer: Aetna Commercial |
$5,020.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,797.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,956.34
|
| Rate for Payer: Cash Price |
$1,673.40
|
| Rate for Payer: Cigna Commercial |
$5,131.76
|
| Rate for Payer: Health EOS Commercial |
$4,964.42
|
| Rate for Payer: HFN Commercial |
$5,131.76
|
| Rate for Payer: Multiplan Commercial |
$4,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,346.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,131.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,733.22
|
| Rate for Payer: Quartz Commercial |
$3,346.80
|
| Rate for Payer: WEA Trust Commercial |
$3,067.90
|
| Rate for Payer: WPS Commercial |
$4,131.62
|
|
|
FEMORAL HEAD VERSYS 28MM +0 8018-28-02
|
Facility
|
OP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,353.24 |
| Max. Negotiated Rate |
$19,332.00 |
| Rate for Payer: Aetna Commercial |
$4,349.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,156.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,353.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,141.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,416.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,319.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,561.49
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,446.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,704.55
|
| Rate for Payer: Health EOS Commercial |
$4,301.37
|
| Rate for Payer: HFN Commercial |
$4,446.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,624.75
|
| Rate for Payer: Multiplan Commercial |
$3,866.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,899.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,446.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,368.17
|
| Rate for Payer: Quartz Commercial |
$3,141.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,899.80
|
| Rate for Payer: The Alliance Commercial |
$19,332.00
|
| Rate for Payer: WEA Trust Commercial |
$2,658.15
|
| Rate for Payer: WPS Commercial |
$3,579.80
|
|
|
FEMORAL HEAD VERSYS 28MM +0 8018-28-02
|
Facility
|
IP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,368.17 |
| Max. Negotiated Rate |
$4,446.36 |
| Rate for Payer: Aetna Commercial |
$4,349.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,156.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,561.49
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,446.36
|
| Rate for Payer: Health EOS Commercial |
$4,301.37
|
| Rate for Payer: HFN Commercial |
$4,446.36
|
| Rate for Payer: Multiplan Commercial |
$3,866.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,899.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,446.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,368.17
|
| Rate for Payer: Quartz Commercial |
$2,899.80
|
| Rate for Payer: WEA Trust Commercial |
$2,658.15
|
| Rate for Payer: WPS Commercial |
$3,579.80
|
|
|
FEMORAL HEAD VERSYS 28MM +10.5 8018-28-05
|
Facility
|
IP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967873
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.97 |
| Max. Negotiated Rate |
$4,280.76 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$2,791.80
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD VERSYS 28MM +10.5 8018-28-05
|
Facility
|
OP
|
$4,653.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967873
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,302.84 |
| Max. Negotiated Rate |
$18,612.00 |
| Rate for Payer: Aetna Commercial |
$4,187.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,001.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,302.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,024.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,326.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,466.09
|
| Rate for Payer: Cash Price |
$1,395.90
|
| Rate for Payer: Cigna Commercial |
$4,280.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,603.82
|
| Rate for Payer: Health EOS Commercial |
$4,141.17
|
| Rate for Payer: HFN Commercial |
$4,280.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,489.75
|
| Rate for Payer: Multiplan Commercial |
$3,722.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,791.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,280.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,279.97
|
| Rate for Payer: Quartz Commercial |
$3,024.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,791.80
|
| Rate for Payer: The Alliance Commercial |
$18,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,559.15
|
| Rate for Payer: WPS Commercial |
$3,446.48
|
|
|
FEMORAL HEAD VERSYS 28MM -3.5 8018-28-01
|
Facility
|
OP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3138916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,353.24 |
| Max. Negotiated Rate |
$19,332.00 |
| Rate for Payer: Aetna Commercial |
$4,349.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,156.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,353.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,141.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,416.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,319.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,561.49
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,446.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,704.55
|
| Rate for Payer: Health EOS Commercial |
$4,301.37
|
| Rate for Payer: HFN Commercial |
$4,446.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,624.75
|
| Rate for Payer: Multiplan Commercial |
$3,866.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,899.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,446.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,368.17
|
| Rate for Payer: Quartz Commercial |
$3,141.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,899.80
|
| Rate for Payer: The Alliance Commercial |
$19,332.00
|
| Rate for Payer: WEA Trust Commercial |
$2,658.15
|
| Rate for Payer: WPS Commercial |
$3,579.80
|
|
|
FEMORAL HEAD VERSYS 28MM -3.5 8018-28-01
|
Facility
|
IP
|
$4,833.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3138916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,368.17 |
| Max. Negotiated Rate |
$4,446.36 |
| Rate for Payer: Aetna Commercial |
$4,349.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,156.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,561.49
|
| Rate for Payer: Cash Price |
$1,449.90
|
| Rate for Payer: Cigna Commercial |
$4,446.36
|
| Rate for Payer: Health EOS Commercial |
$4,301.37
|
| Rate for Payer: HFN Commercial |
$4,446.36
|
| Rate for Payer: Multiplan Commercial |
$3,866.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,899.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,446.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,368.17
|
| Rate for Payer: Quartz Commercial |
$2,899.80
|
| Rate for Payer: WEA Trust Commercial |
$2,658.15
|
| Rate for Payer: WPS Commercial |
$3,579.80
|
|
