|
FEMORAL STEM AVENIR MULLER STD SZ 2 01.06010.202
|
Facility
|
IP
|
$15,490.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4858762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,893.70 |
| Max. Negotiated Rate |
$14,820.83 |
| Rate for Payer: Aetna Commercial |
$14,498.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,854.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,538.09
|
| Rate for Payer: Cash Price |
$4,647.00
|
| Rate for Payer: Cigna Commercial |
$14,820.83
|
| Rate for Payer: Health EOS Commercial |
$14,337.54
|
| Rate for Payer: HFN Commercial |
$14,820.83
|
| Rate for Payer: Multiplan Commercial |
$12,887.68
|
| Rate for Payer: Preferred Network Access Commercial |
$14,820.83
|
| Rate for Payer: Quartz Beloit One Network |
$7,893.70
|
| Rate for Payer: Quartz Commercial |
$9,665.76
|
| Rate for Payer: WEA Trust Commercial |
$8,860.28
|
| Rate for Payer: WPS Commercial |
$11,931.95
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 3 01.06010.003
|
Facility
|
IP
|
$16,085.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5307093
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,196.92 |
| Max. Negotiated Rate |
$15,390.13 |
| Rate for Payer: Aetna Commercial |
$15,055.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,386.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,866.05
|
| Rate for Payer: Cash Price |
$4,825.50
|
| Rate for Payer: Cigna Commercial |
$15,390.13
|
| Rate for Payer: Health EOS Commercial |
$14,888.28
|
| Rate for Payer: HFN Commercial |
$15,390.13
|
| Rate for Payer: Multiplan Commercial |
$13,382.72
|
| Rate for Payer: Preferred Network Access Commercial |
$15,390.13
|
| Rate for Payer: Quartz Beloit One Network |
$8,196.92
|
| Rate for Payer: Quartz Commercial |
$10,037.04
|
| Rate for Payer: WEA Trust Commercial |
$9,200.62
|
| Rate for Payer: WPS Commercial |
$12,390.28
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 3 01.06010.003
|
Facility
|
OP
|
$16,085.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5307093
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,683.95 |
| Max. Negotiated Rate |
$15,390.13 |
| Rate for Payer: Aetna Commercial |
$15,055.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,386.42
|
| Rate for Payer: Aetna Managed Medicare |
$4,683.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,873.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,029.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,866.05
|
| Rate for Payer: Cash Price |
$4,825.50
|
| Rate for Payer: Cigna Commercial |
$15,390.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,361.47
|
| Rate for Payer: Health EOS Commercial |
$14,888.28
|
| Rate for Payer: HFN Commercial |
$15,390.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,546.30
|
| Rate for Payer: Multiplan Commercial |
$13,382.72
|
| Rate for Payer: NAPHCARE Commercial |
$10,037.04
|
| Rate for Payer: Preferred Network Access Commercial |
$15,390.13
|
| Rate for Payer: Quartz Beloit One Network |
$8,196.92
|
| Rate for Payer: Quartz Commercial |
$10,873.46
|
| Rate for Payer: Quartz Medicare Advantage |
$10,037.04
|
| Rate for Payer: The Alliance Commercial |
$8,364.20
|
| Rate for Payer: WEA Trust Commercial |
$9,200.62
|
| Rate for Payer: WPS Commercial |
$12,390.28
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 4 01.06010.004
|
Facility
|
IP
|
$16,085.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4640957
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,196.92 |
| Max. Negotiated Rate |
$15,390.13 |
| Rate for Payer: Aetna Commercial |
$15,055.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,386.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,866.05
|
| Rate for Payer: Cash Price |
$4,825.50
|
| Rate for Payer: Cigna Commercial |
$15,390.13
|
| Rate for Payer: Health EOS Commercial |
$14,888.28
|
| Rate for Payer: HFN Commercial |
$15,390.13
|
| Rate for Payer: Multiplan Commercial |
$13,382.72
|
| Rate for Payer: Preferred Network Access Commercial |
$15,390.13
|
| Rate for Payer: Quartz Beloit One Network |
$8,196.92
|
| Rate for Payer: Quartz Commercial |
$10,037.04
|
| Rate for Payer: WEA Trust Commercial |
$9,200.62
|
| Rate for Payer: WPS Commercial |
$12,390.28
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 4 01.06010.004
|
Facility
|
OP
|
$16,085.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4640957
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,683.95 |
| Max. Negotiated Rate |
$15,390.13 |
| Rate for Payer: Aetna Commercial |
$15,055.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,386.42
|
| Rate for Payer: Aetna Managed Medicare |
$4,683.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,873.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,029.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,866.05
|
| Rate for Payer: Cash Price |
$4,825.50
|
| Rate for Payer: Cigna Commercial |
$15,390.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,361.47
|
| Rate for Payer: Health EOS Commercial |
$14,888.28
|
| Rate for Payer: HFN Commercial |
$15,390.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,546.30
|
| Rate for Payer: Multiplan Commercial |
$13,382.72
|
| Rate for Payer: NAPHCARE Commercial |
$10,037.04
|
| Rate for Payer: Preferred Network Access Commercial |
$15,390.13
|
| Rate for Payer: Quartz Beloit One Network |
$8,196.92
|
| Rate for Payer: Quartz Commercial |
$10,873.46
|
| Rate for Payer: Quartz Medicare Advantage |
$10,037.04
|
| Rate for Payer: The Alliance Commercial |
$8,364.20
|
| Rate for Payer: WEA Trust Commercial |
$9,200.62
|
| Rate for Payer: WPS Commercial |
$12,390.28
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 5 01.06010.005
|
Facility
|
IP
|
$12,192.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6220192
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,213.04 |
| Max. Negotiated Rate |
$11,665.31 |
| Rate for Payer: Aetna Commercial |
$11,411.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,904.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,720.23
|
| Rate for Payer: Cash Price |
$3,657.60
|
| Rate for Payer: Cigna Commercial |
$11,665.31
|
| Rate for Payer: Health EOS Commercial |
$11,284.92
|
| Rate for Payer: HFN Commercial |
$11,665.31
|
| Rate for Payer: Multiplan Commercial |
$10,143.74
|
| Rate for Payer: Preferred Network Access Commercial |
$11,665.31
|
| Rate for Payer: Quartz Beloit One Network |
$6,213.04
|
| Rate for Payer: Quartz Commercial |
$7,607.81
|
| Rate for Payer: WEA Trust Commercial |
$6,973.82
|
| Rate for Payer: WPS Commercial |
$9,391.50
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 5 01.06010.005
|
Facility
|
OP
|
$12,192.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6220192
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,550.31 |
| Max. Negotiated Rate |
$11,665.31 |
| Rate for Payer: Aetna Commercial |
$11,411.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,904.52
|
| Rate for Payer: Aetna Managed Medicare |
$3,550.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,241.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,339.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,086.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,720.23
|
| Rate for Payer: Cash Price |
$3,657.60
|
| Rate for Payer: Cigna Commercial |
$11,665.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,095.74
|
| Rate for Payer: Health EOS Commercial |
$11,284.92
|
| Rate for Payer: HFN Commercial |
$11,665.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,509.76
|
| Rate for Payer: Multiplan Commercial |
$10,143.74
|
| Rate for Payer: NAPHCARE Commercial |
$7,607.81
|
| Rate for Payer: Preferred Network Access Commercial |
$11,665.31
|
| Rate for Payer: Quartz Beloit One Network |
$6,213.04
|
| Rate for Payer: Quartz Commercial |
$8,241.79
|
| Rate for Payer: Quartz Medicare Advantage |
$7,607.81
|
| Rate for Payer: The Alliance Commercial |
$6,339.84
|
| Rate for Payer: WEA Trust Commercial |
$6,973.82
|
| Rate for Payer: WPS Commercial |
$9,391.50
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 6 01.06010.006
|
Facility
|
IP
|
$16,085.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456752
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,196.92 |
| Max. Negotiated Rate |
$15,390.13 |
| Rate for Payer: Aetna Commercial |
$15,055.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,386.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,866.05
|
| Rate for Payer: Cash Price |
$4,825.50
|
| Rate for Payer: Cigna Commercial |
$15,390.13
|
| Rate for Payer: Health EOS Commercial |
$14,888.28
|
| Rate for Payer: HFN Commercial |
$15,390.13
|
| Rate for Payer: Multiplan Commercial |
$13,382.72
|
| Rate for Payer: Preferred Network Access Commercial |
$15,390.13
|
| Rate for Payer: Quartz Beloit One Network |
$8,196.92
|
| Rate for Payer: Quartz Commercial |
$10,037.04
|
| Rate for Payer: WEA Trust Commercial |
$9,200.62
|
| Rate for Payer: WPS Commercial |
$12,390.28
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 6 01.06010.006
|
Facility
|
OP
|
$16,085.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456752
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,683.95 |
| Max. Negotiated Rate |
$15,390.13 |
| Rate for Payer: Aetna Commercial |
$15,055.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,386.42
|
| Rate for Payer: Aetna Managed Medicare |
$4,683.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,873.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,029.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,866.05
|
| Rate for Payer: Cash Price |
$4,825.50
|
| Rate for Payer: Cigna Commercial |
$15,390.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,361.47
|
| Rate for Payer: Health EOS Commercial |
$14,888.28
|
| Rate for Payer: HFN Commercial |
$15,390.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,546.30
|
| Rate for Payer: Multiplan Commercial |
$13,382.72
|
| Rate for Payer: NAPHCARE Commercial |
$10,037.04
|
| Rate for Payer: Preferred Network Access Commercial |
$15,390.13
|
| Rate for Payer: Quartz Beloit One Network |
$8,196.92
|
| Rate for Payer: Quartz Commercial |
$10,873.46
|
| Rate for Payer: Quartz Medicare Advantage |
$10,037.04
|
| Rate for Payer: The Alliance Commercial |
$8,364.20
|
| Rate for Payer: WEA Trust Commercial |
$9,200.62
|
| Rate for Payer: WPS Commercial |
$12,390.28
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 6 CEM 01.06010.206
|
Facility
|
OP
|
$9,810.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,856.84 |
| Max. Negotiated Rate |
$9,386.76 |
| Rate for Payer: Aetna Commercial |
$9,182.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,774.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,856.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,631.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,101.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,897.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,407.59
|
| Rate for Payer: Cash Price |
$2,943.17
|
| Rate for Payer: Cigna Commercial |
$9,386.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,709.76
|
| Rate for Payer: Health EOS Commercial |
$9,080.67
|
| Rate for Payer: HFN Commercial |
$9,386.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,652.25
|
| Rate for Payer: Multiplan Commercial |
$8,162.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,121.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,386.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,999.47
|
| Rate for Payer: Quartz Commercial |
$6,631.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,121.80
|
| Rate for Payer: The Alliance Commercial |
$5,101.50
|
| Rate for Payer: WEA Trust Commercial |
$5,611.65
|
| Rate for Payer: WPS Commercial |
$7,557.09
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 6 CEM 01.06010.206
|
Facility
|
IP
|
$9,810.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,999.47 |
| Max. Negotiated Rate |
$9,386.76 |
| Rate for Payer: Aetna Commercial |
$9,182.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,774.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,407.59
|
| Rate for Payer: Cash Price |
$2,943.17
|
| Rate for Payer: Cigna Commercial |
$9,386.76
|
| Rate for Payer: Health EOS Commercial |
$9,080.67
|
| Rate for Payer: HFN Commercial |
$9,386.76
|
| Rate for Payer: Multiplan Commercial |
$8,162.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,386.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,999.47
|
| Rate for Payer: Quartz Commercial |
$6,121.80
|
| Rate for Payer: WEA Trust Commercial |
$5,611.65
|
| Rate for Payer: WPS Commercial |
$7,557.09
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 7 01.06010.007
|
Facility
|
IP
|
$15,490.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,893.70 |
| Max. Negotiated Rate |
$14,820.83 |
| Rate for Payer: Aetna Commercial |
$14,498.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,854.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,538.09
|
| Rate for Payer: Cash Price |
$4,647.00
|
| Rate for Payer: Cigna Commercial |
$14,820.83
|
| Rate for Payer: Health EOS Commercial |
$14,337.54
|
| Rate for Payer: HFN Commercial |
$14,820.83
|
| Rate for Payer: Multiplan Commercial |
$12,887.68
|
| Rate for Payer: Preferred Network Access Commercial |
$14,820.83
|
| Rate for Payer: Quartz Beloit One Network |
$7,893.70
|
| Rate for Payer: Quartz Commercial |
$9,665.76
|
| Rate for Payer: WEA Trust Commercial |
$8,860.28
|
| Rate for Payer: WPS Commercial |
$11,931.95
|
|
|
FEMORAL STEM AVENIR MULLER STD SZ 7 01.06010.007
|
Facility
|
OP
|
$15,490.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,510.69 |
| Max. Negotiated Rate |
$14,820.83 |
| Rate for Payer: Aetna Commercial |
$14,498.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,854.26
|
| Rate for Payer: Aetna Managed Medicare |
$4,510.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,471.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,054.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,732.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,538.09
|
| Rate for Payer: Cash Price |
$4,647.00
|
| Rate for Payer: Cigna Commercial |
$14,820.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,015.18
|
| Rate for Payer: Health EOS Commercial |
$14,337.54
|
| Rate for Payer: HFN Commercial |
$14,820.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,082.20
|
| Rate for Payer: Multiplan Commercial |
$12,887.68
|
| Rate for Payer: NAPHCARE Commercial |
$9,665.76
|
| Rate for Payer: Preferred Network Access Commercial |
$14,820.83
|
| Rate for Payer: Quartz Beloit One Network |
$7,893.70
|
| Rate for Payer: Quartz Commercial |
$10,471.24
|
| Rate for Payer: Quartz Medicare Advantage |
$9,665.76
|
| Rate for Payer: The Alliance Commercial |
$8,054.80
|
| Rate for Payer: WEA Trust Commercial |
$8,860.28
|
| Rate for Payer: WPS Commercial |
$11,931.95
|
|
|
FEMORAL STEM CORAIL COATED REVISION 135 DEG STD COLLAR SZ 11 L98011
|
Facility
|
OP
|
$55,092.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,042.79 |
| Max. Negotiated Rate |
$52,712.03 |
| Rate for Payer: Aetna Commercial |
$51,566.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49,274.28
|
| Rate for Payer: Aetna Managed Medicare |
$16,042.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37,242.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,647.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,501.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30,366.71
|
| Rate for Payer: Cash Price |
$16,527.60
|
| Rate for Payer: Cigna Commercial |
$52,712.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32,063.54
|
| Rate for Payer: Health EOS Commercial |
$50,993.16
|
| Rate for Payer: HFN Commercial |
$52,712.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42,971.76
|
| Rate for Payer: Multiplan Commercial |
$45,836.54
|
| Rate for Payer: NAPHCARE Commercial |
$34,377.41
|
| Rate for Payer: Preferred Network Access Commercial |
$52,712.03
|
| Rate for Payer: Quartz Beloit One Network |
$28,074.88
|
| Rate for Payer: Quartz Commercial |
$37,242.19
|
| Rate for Payer: Quartz Medicare Advantage |
$34,377.41
|
| Rate for Payer: The Alliance Commercial |
$28,647.84
|
| Rate for Payer: WEA Trust Commercial |
$31,512.62
|
| Rate for Payer: WPS Commercial |
$42,437.37
|
|
|
FEMORAL STEM CORAIL COATED REVISION 135 DEG STD COLLAR SZ 11 L98011
|
Facility
|
IP
|
$55,092.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$28,074.88 |
| Max. Negotiated Rate |
$52,712.03 |
| Rate for Payer: Aetna Commercial |
$51,566.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49,274.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30,366.71
|
| Rate for Payer: Cash Price |
$16,527.60
|
| Rate for Payer: Cigna Commercial |
$52,712.03
|
| Rate for Payer: Health EOS Commercial |
$50,993.16
|
| Rate for Payer: HFN Commercial |
$52,712.03
|
| Rate for Payer: Multiplan Commercial |
$45,836.54
|
| Rate for Payer: Preferred Network Access Commercial |
$52,712.03
|
| Rate for Payer: Quartz Beloit One Network |
$28,074.88
|
| Rate for Payer: Quartz Commercial |
$34,377.41
|
| Rate for Payer: WEA Trust Commercial |
$31,512.62
|
| Rate for Payer: WPS Commercial |
$42,437.37
|
|
|
FEMORAL STEM SUMMIT SZ 12/14 TAPER 1570-13-090
|
Facility
|
OP
|
$9,016.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,625.46 |
| Max. Negotiated Rate |
$8,626.51 |
| Rate for Payer: Aetna Commercial |
$8,438.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,063.91
|
| Rate for Payer: Aetna Managed Medicare |
$2,625.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,094.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,688.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,500.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,969.62
|
| Rate for Payer: Cash Price |
$2,704.80
|
| Rate for Payer: Cigna Commercial |
$8,626.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,247.31
|
| Rate for Payer: Health EOS Commercial |
$8,345.21
|
| Rate for Payer: HFN Commercial |
$8,626.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,032.48
|
| Rate for Payer: Multiplan Commercial |
$7,501.31
|
| Rate for Payer: NAPHCARE Commercial |
$5,625.98
|
| Rate for Payer: Preferred Network Access Commercial |
$8,626.51
|
| Rate for Payer: Quartz Beloit One Network |
$4,594.55
|
| Rate for Payer: Quartz Commercial |
$6,094.82
|
| Rate for Payer: Quartz Medicare Advantage |
$5,625.98
|
| Rate for Payer: The Alliance Commercial |
$4,688.32
|
| Rate for Payer: WEA Trust Commercial |
$5,157.15
|
| Rate for Payer: WPS Commercial |
$6,945.02
|
|
|
FEMORAL STEM SUMMIT SZ 12/14 TAPER 1570-13-090
|
Facility
|
IP
|
$9,016.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,594.55 |
| Max. Negotiated Rate |
$8,626.51 |
| Rate for Payer: Aetna Commercial |
$8,438.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,063.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,969.62
|
| Rate for Payer: Cash Price |
$2,704.80
|
| Rate for Payer: Cigna Commercial |
$8,626.51
|
| Rate for Payer: Health EOS Commercial |
$8,345.21
|
| Rate for Payer: HFN Commercial |
$8,626.51
|
| Rate for Payer: Multiplan Commercial |
$7,501.31
|
| Rate for Payer: Preferred Network Access Commercial |
$8,626.51
|
| Rate for Payer: Quartz Beloit One Network |
$4,594.55
|
| Rate for Payer: Quartz Commercial |
$5,625.98
|
| Rate for Payer: WEA Trust Commercial |
$5,157.15
|
| Rate for Payer: WPS Commercial |
$6,945.02
|
|
|
FEMORAL STEM SUMMIT SZ 2 STD CEMENTED 1570-03-080
|
Facility
|
IP
|
$9,573.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563459
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,878.40 |
| Max. Negotiated Rate |
$9,159.45 |
| Rate for Payer: Aetna Commercial |
$8,960.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,562.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,276.64
|
| Rate for Payer: Cash Price |
$2,871.90
|
| Rate for Payer: Cigna Commercial |
$9,159.45
|
| Rate for Payer: Health EOS Commercial |
$8,860.77
|
| Rate for Payer: HFN Commercial |
$9,159.45
|
| Rate for Payer: Multiplan Commercial |
$7,964.74
|
| Rate for Payer: Preferred Network Access Commercial |
$9,159.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,878.40
|
| Rate for Payer: Quartz Commercial |
$5,973.55
|
| Rate for Payer: WEA Trust Commercial |
$5,475.76
|
| Rate for Payer: WPS Commercial |
$7,374.08
|
|
|
FEMORAL STEM SUMMIT SZ 2 STD CEMENTED 1570-03-080
|
Facility
|
OP
|
$9,573.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563459
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,787.66 |
| Max. Negotiated Rate |
$9,159.45 |
| Rate for Payer: Aetna Commercial |
$8,960.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,562.09
|
| Rate for Payer: Aetna Managed Medicare |
$2,787.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,471.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,977.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,778.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,276.64
|
| Rate for Payer: Cash Price |
$2,871.90
|
| Rate for Payer: Cigna Commercial |
$9,159.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,571.49
|
| Rate for Payer: Health EOS Commercial |
$8,860.77
|
| Rate for Payer: HFN Commercial |
$9,159.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,466.94
|
| Rate for Payer: Multiplan Commercial |
$7,964.74
|
| Rate for Payer: NAPHCARE Commercial |
$5,973.55
|
| Rate for Payer: Preferred Network Access Commercial |
$9,159.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,878.40
|
| Rate for Payer: Quartz Commercial |
$6,471.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,973.55
|
| Rate for Payer: The Alliance Commercial |
$4,977.96
|
| Rate for Payer: WEA Trust Commercial |
$5,475.76
|
| Rate for Payer: WPS Commercial |
$7,374.08
|
|
|
FEMORAL STEM SUMMIT SZ 3 12/14 TAPER 1570-01-090
|
Facility
|
IP
|
$16,595.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,456.81 |
| Max. Negotiated Rate |
$15,878.10 |
| Rate for Payer: Aetna Commercial |
$15,532.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,842.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,147.16
|
| Rate for Payer: Cash Price |
$4,978.50
|
| Rate for Payer: Cigna Commercial |
$15,878.10
|
| Rate for Payer: Health EOS Commercial |
$15,360.33
|
| Rate for Payer: HFN Commercial |
$15,878.10
|
| Rate for Payer: Multiplan Commercial |
$13,807.04
|
| Rate for Payer: Preferred Network Access Commercial |
$15,878.10
|
| Rate for Payer: Quartz Beloit One Network |
$8,456.81
|
| Rate for Payer: Quartz Commercial |
$10,355.28
|
| Rate for Payer: WEA Trust Commercial |
$9,492.34
|
| Rate for Payer: WPS Commercial |
$12,783.13
|
|
|
FEMORAL STEM SUMMIT SZ 3 12/14 TAPER 1570-01-090
|
Facility
|
OP
|
$16,595.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,832.46 |
| Max. Negotiated Rate |
$15,878.10 |
| Rate for Payer: Aetna Commercial |
$15,532.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,842.57
|
| Rate for Payer: Aetna Managed Medicare |
$4,832.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,218.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,629.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,284.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,147.16
|
| Rate for Payer: Cash Price |
$4,978.50
|
| Rate for Payer: Cigna Commercial |
$15,878.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,658.29
|
| Rate for Payer: Health EOS Commercial |
$15,360.33
|
| Rate for Payer: HFN Commercial |
$15,878.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,944.10
|
| Rate for Payer: Multiplan Commercial |
$13,807.04
|
| Rate for Payer: NAPHCARE Commercial |
$10,355.28
|
| Rate for Payer: Preferred Network Access Commercial |
$15,878.10
|
| Rate for Payer: Quartz Beloit One Network |
$8,456.81
|
| Rate for Payer: Quartz Commercial |
$11,218.22
|
| Rate for Payer: Quartz Medicare Advantage |
$10,355.28
|
| Rate for Payer: The Alliance Commercial |
$8,629.40
|
| Rate for Payer: WEA Trust Commercial |
$9,492.34
|
| Rate for Payer: WPS Commercial |
$12,783.13
|
|
|
FEMORAL STEM SUMMIT SZ 3 12/14 TAPER 1570-11-090
|
Facility
|
IP
|
$17,234.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,782.45 |
| Max. Negotiated Rate |
$16,489.49 |
| Rate for Payer: Aetna Commercial |
$16,131.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,414.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,499.38
|
| Rate for Payer: Cash Price |
$5,170.20
|
| Rate for Payer: Cigna Commercial |
$16,489.49
|
| Rate for Payer: Health EOS Commercial |
$15,951.79
|
| Rate for Payer: HFN Commercial |
$16,489.49
|
| Rate for Payer: Multiplan Commercial |
$14,338.69
|
| Rate for Payer: Preferred Network Access Commercial |
$16,489.49
|
| Rate for Payer: Quartz Beloit One Network |
$8,782.45
|
| Rate for Payer: Quartz Commercial |
$10,754.02
|
| Rate for Payer: WEA Trust Commercial |
$9,857.85
|
| Rate for Payer: WPS Commercial |
$13,275.35
|
|
|
FEMORAL STEM SUMMIT SZ 3 12/14 TAPER 1570-11-090
|
Facility
|
OP
|
$17,234.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,018.54 |
| Max. Negotiated Rate |
$16,489.49 |
| Rate for Payer: Aetna Commercial |
$16,131.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,414.09
|
| Rate for Payer: Aetna Managed Medicare |
$5,018.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,650.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,961.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,603.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,499.38
|
| Rate for Payer: Cash Price |
$5,170.20
|
| Rate for Payer: Cigna Commercial |
$16,489.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,030.19
|
| Rate for Payer: Health EOS Commercial |
$15,951.79
|
| Rate for Payer: HFN Commercial |
$16,489.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,442.52
|
| Rate for Payer: Multiplan Commercial |
$14,338.69
|
| Rate for Payer: NAPHCARE Commercial |
$10,754.02
|
| Rate for Payer: Preferred Network Access Commercial |
$16,489.49
|
| Rate for Payer: Quartz Beloit One Network |
$8,782.45
|
| Rate for Payer: Quartz Commercial |
$11,650.18
|
| Rate for Payer: Quartz Medicare Advantage |
$10,754.02
|
| Rate for Payer: The Alliance Commercial |
$8,961.68
|
| Rate for Payer: WEA Trust Commercial |
$9,857.85
|
| Rate for Payer: WPS Commercial |
$13,275.35
|
|
|
FEMORAL STEM SUMMIT SZ 3 STD CEMENTED 1570-03-090
|
Facility
|
IP
|
$9,956.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5490780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,073.58 |
| Max. Negotiated Rate |
$9,525.90 |
| Rate for Payer: Aetna Commercial |
$9,318.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,904.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,487.75
|
| Rate for Payer: Cash Price |
$2,986.80
|
| Rate for Payer: Cigna Commercial |
$9,525.90
|
| Rate for Payer: Health EOS Commercial |
$9,215.27
|
| Rate for Payer: HFN Commercial |
$9,525.90
|
| Rate for Payer: Multiplan Commercial |
$8,283.39
|
| Rate for Payer: Preferred Network Access Commercial |
$9,525.90
|
| Rate for Payer: Quartz Beloit One Network |
$5,073.58
|
| Rate for Payer: Quartz Commercial |
$6,212.54
|
| Rate for Payer: WEA Trust Commercial |
$5,694.83
|
| Rate for Payer: WPS Commercial |
$7,669.11
|
|
|
FEMORAL STEM SUMMIT SZ 3 STD CEMENTED 1570-03-090
|
Facility
|
OP
|
$9,956.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5490780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,899.19 |
| Max. Negotiated Rate |
$9,525.90 |
| Rate for Payer: Aetna Commercial |
$9,318.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,904.65
|
| Rate for Payer: Aetna Managed Medicare |
$2,899.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,730.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,177.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,970.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,487.75
|
| Rate for Payer: Cash Price |
$2,986.80
|
| Rate for Payer: Cigna Commercial |
$9,525.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,794.39
|
| Rate for Payer: Health EOS Commercial |
$9,215.27
|
| Rate for Payer: HFN Commercial |
$9,525.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,765.68
|
| Rate for Payer: Multiplan Commercial |
$8,283.39
|
| Rate for Payer: NAPHCARE Commercial |
$6,212.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,525.90
|
| Rate for Payer: Quartz Beloit One Network |
$5,073.58
|
| Rate for Payer: Quartz Commercial |
$6,730.26
|
| Rate for Payer: Quartz Medicare Advantage |
$6,212.54
|
| Rate for Payer: The Alliance Commercial |
$5,177.12
|
| Rate for Payer: WEA Trust Commercial |
$5,694.83
|
| Rate for Payer: WPS Commercial |
$7,669.11
|
|
