|
FEMORAL REVISION CRS ATTUNE SZ 5 LT CEMENTED 1504-40-105
|
Facility
|
IP
|
$33,814.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6226145
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,568.86 |
| Max. Negotiated Rate |
$31,108.88 |
| Rate for Payer: Aetna Commercial |
$30,432.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29,080.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,921.42
|
| Rate for Payer: Cash Price |
$10,144.20
|
| Rate for Payer: Cigna Commercial |
$31,108.88
|
| Rate for Payer: Health EOS Commercial |
$30,094.46
|
| Rate for Payer: HFN Commercial |
$31,108.88
|
| Rate for Payer: Multiplan Commercial |
$27,051.20
|
| Rate for Payer: NAPHCARE Commercial |
$20,288.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31,108.88
|
| Rate for Payer: Quartz Beloit One Network |
$16,568.86
|
| Rate for Payer: Quartz Commercial |
$20,288.40
|
| Rate for Payer: WEA Trust Commercial |
$18,597.70
|
| Rate for Payer: WPS Commercial |
$25,046.03
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 6 RT CEMENTED 1504-40-206
|
Facility
|
IP
|
$30,712.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6201076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,048.88 |
| Max. Negotiated Rate |
$28,255.04 |
| Rate for Payer: Aetna Commercial |
$27,640.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26,412.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,277.36
|
| Rate for Payer: Cash Price |
$9,213.60
|
| Rate for Payer: Cigna Commercial |
$28,255.04
|
| Rate for Payer: Health EOS Commercial |
$27,333.68
|
| Rate for Payer: HFN Commercial |
$28,255.04
|
| Rate for Payer: Multiplan Commercial |
$24,569.60
|
| Rate for Payer: NAPHCARE Commercial |
$18,427.20
|
| Rate for Payer: Preferred Network Access Commercial |
$28,255.04
|
| Rate for Payer: Quartz Beloit One Network |
$15,048.88
|
| Rate for Payer: Quartz Commercial |
$18,427.20
|
| Rate for Payer: WEA Trust Commercial |
$16,891.60
|
| Rate for Payer: WPS Commercial |
$22,748.38
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 6 RT CEMENTED 1504-40-206
|
Facility
|
OP
|
$30,712.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6201076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,599.36 |
| Max. Negotiated Rate |
$122,848.00 |
| Rate for Payer: Aetna Commercial |
$27,640.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26,412.32
|
| Rate for Payer: Aetna Managed Medicare |
$8,599.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,962.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,356.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,741.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,277.36
|
| Rate for Payer: Cash Price |
$9,213.60
|
| Rate for Payer: Cigna Commercial |
$28,255.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,186.44
|
| Rate for Payer: Health EOS Commercial |
$27,333.68
|
| Rate for Payer: HFN Commercial |
$28,255.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,034.00
|
| Rate for Payer: Multiplan Commercial |
$24,569.60
|
| Rate for Payer: NAPHCARE Commercial |
$18,427.20
|
| Rate for Payer: Preferred Network Access Commercial |
$28,255.04
|
| Rate for Payer: Quartz Beloit One Network |
$15,048.88
|
| Rate for Payer: Quartz Commercial |
$19,962.80
|
| Rate for Payer: Quartz Medicare Advantage |
$18,427.20
|
| Rate for Payer: The Alliance Commercial |
$122,848.00
|
| Rate for Payer: WEA Trust Commercial |
$16,891.60
|
| Rate for Payer: WPS Commercial |
$22,748.38
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 7 LT CEMENTED 1504-40-107
|
Facility
|
IP
|
$31,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6165875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,650.60 |
| Max. Negotiated Rate |
$29,384.80 |
| Rate for Payer: Aetna Commercial |
$28,746.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,468.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,928.20
|
| Rate for Payer: Cash Price |
$9,582.00
|
| Rate for Payer: Cigna Commercial |
$29,384.80
|
| Rate for Payer: Health EOS Commercial |
$28,426.60
|
| Rate for Payer: HFN Commercial |
$29,384.80
|
| Rate for Payer: Multiplan Commercial |
$25,552.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,164.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,384.80
|
| Rate for Payer: Quartz Beloit One Network |
$15,650.60
|
| Rate for Payer: Quartz Commercial |
$19,164.00
|
| Rate for Payer: WEA Trust Commercial |
$17,567.00
|
| Rate for Payer: WPS Commercial |
$23,657.96
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 7 LT CEMENTED 1504-40-107
|
Facility
|
OP
|
$31,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6165875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,943.20 |
| Max. Negotiated Rate |
$127,760.00 |
| Rate for Payer: Aetna Commercial |
$28,746.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,468.40
|
| Rate for Payer: Aetna Managed Medicare |
$8,943.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,761.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,970.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,331.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16,928.20
|
| Rate for Payer: Cash Price |
$9,582.00
|
| Rate for Payer: Cigna Commercial |
$29,384.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,873.62
|
| Rate for Payer: Health EOS Commercial |
$28,426.60
|
| Rate for Payer: HFN Commercial |
$29,384.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,955.00
|
| Rate for Payer: Multiplan Commercial |
$25,552.00
|
| Rate for Payer: NAPHCARE Commercial |
$19,164.00
|
| Rate for Payer: Preferred Network Access Commercial |
$29,384.80
|
| Rate for Payer: Quartz Beloit One Network |
$15,650.60
|
| Rate for Payer: Quartz Commercial |
$20,761.00
|
| Rate for Payer: Quartz Medicare Advantage |
$19,164.00
|
| Rate for Payer: The Alliance Commercial |
$127,760.00
|
| Rate for Payer: WEA Trust Commercial |
$17,567.00
|
| Rate for Payer: WPS Commercial |
$23,657.96
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 7 RT CEMENTED 1504-40-207
|
Facility
|
IP
|
$49,378.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24,195.22 |
| Max. Negotiated Rate |
$45,427.76 |
| Rate for Payer: Aetna Commercial |
$44,440.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42,465.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26,170.34
|
| Rate for Payer: Cash Price |
$14,813.40
|
| Rate for Payer: Cigna Commercial |
$45,427.76
|
| Rate for Payer: Health EOS Commercial |
$43,946.42
|
| Rate for Payer: HFN Commercial |
$45,427.76
|
| Rate for Payer: Multiplan Commercial |
$39,502.40
|
| Rate for Payer: NAPHCARE Commercial |
$29,626.80
|
| Rate for Payer: Preferred Network Access Commercial |
$45,427.76
|
| Rate for Payer: Quartz Beloit One Network |
$24,195.22
|
| Rate for Payer: Quartz Commercial |
$29,626.80
|
| Rate for Payer: WEA Trust Commercial |
$27,157.90
|
| Rate for Payer: WPS Commercial |
$36,574.28
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 7 RT CEMENTED 1504-40-207
|
Facility
|
OP
|
$49,378.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,825.84 |
| Max. Negotiated Rate |
$197,512.00 |
| Rate for Payer: Aetna Commercial |
$44,440.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42,465.08
|
| Rate for Payer: Aetna Managed Medicare |
$13,825.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32,095.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,701.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26,170.34
|
| Rate for Payer: Cash Price |
$14,813.40
|
| Rate for Payer: Cigna Commercial |
$45,427.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,631.93
|
| Rate for Payer: Health EOS Commercial |
$43,946.42
|
| Rate for Payer: HFN Commercial |
$45,427.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,033.50
|
| Rate for Payer: Multiplan Commercial |
$39,502.40
|
| Rate for Payer: NAPHCARE Commercial |
$29,626.80
|
| Rate for Payer: Preferred Network Access Commercial |
$45,427.76
|
| Rate for Payer: Quartz Beloit One Network |
$24,195.22
|
| Rate for Payer: Quartz Commercial |
$32,095.70
|
| Rate for Payer: Quartz Medicare Advantage |
$29,626.80
|
| Rate for Payer: The Alliance Commercial |
$197,512.00
|
| Rate for Payer: WEA Trust Commercial |
$27,157.90
|
| Rate for Payer: WPS Commercial |
$36,574.28
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 8 RT CEMENTED 1504-40-208
|
Facility
|
OP
|
$33,218.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,301.04 |
| Max. Negotiated Rate |
$132,872.00 |
| Rate for Payer: Aetna Commercial |
$29,896.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,567.48
|
| Rate for Payer: Aetna Managed Medicare |
$9,301.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,591.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,609.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,944.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,605.54
|
| Rate for Payer: Cash Price |
$9,965.40
|
| Rate for Payer: Cigna Commercial |
$30,560.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,588.79
|
| Rate for Payer: Health EOS Commercial |
$29,564.02
|
| Rate for Payer: HFN Commercial |
$30,560.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,913.50
|
| Rate for Payer: Multiplan Commercial |
$26,574.40
|
| Rate for Payer: NAPHCARE Commercial |
$19,930.80
|
| Rate for Payer: Preferred Network Access Commercial |
$30,560.56
|
| Rate for Payer: Quartz Beloit One Network |
$16,276.82
|
| Rate for Payer: Quartz Commercial |
$21,591.70
|
| Rate for Payer: Quartz Medicare Advantage |
$19,930.80
|
| Rate for Payer: The Alliance Commercial |
$132,872.00
|
| Rate for Payer: WEA Trust Commercial |
$18,269.90
|
| Rate for Payer: WPS Commercial |
$24,604.57
|
|
|
FEMORAL REVISION CRS ATTUNE SZ 8 RT CEMENTED 1504-40-208
|
Facility
|
IP
|
$33,218.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,276.82 |
| Max. Negotiated Rate |
$30,560.56 |
| Rate for Payer: Aetna Commercial |
$29,896.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,567.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,605.54
|
| Rate for Payer: Cash Price |
$9,965.40
|
| Rate for Payer: Cigna Commercial |
$30,560.56
|
| Rate for Payer: Health EOS Commercial |
$29,564.02
|
| Rate for Payer: HFN Commercial |
$30,560.56
|
| Rate for Payer: Multiplan Commercial |
$26,574.40
|
| Rate for Payer: NAPHCARE Commercial |
$19,930.80
|
| Rate for Payer: Preferred Network Access Commercial |
$30,560.56
|
| Rate for Payer: Quartz Beloit One Network |
$16,276.82
|
| Rate for Payer: Quartz Commercial |
$19,930.80
|
| Rate for Payer: WEA Trust Commercial |
$18,269.90
|
| Rate for Payer: WPS Commercial |
$24,604.57
|
|
|
FEMORAL ROTATING HINGE CEMENTED LT X-SMALL S-ROM NOILES 62-3421L
|
Facility
|
OP
|
$32,339.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,054.92 |
| Max. Negotiated Rate |
$129,356.00 |
| Rate for Payer: Aetna Commercial |
$29,105.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,811.54
|
| Rate for Payer: Aetna Managed Medicare |
$9,054.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,020.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,169.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,522.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,139.67
|
| Rate for Payer: Cash Price |
$9,701.70
|
| Rate for Payer: Cigna Commercial |
$29,751.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,096.90
|
| Rate for Payer: Health EOS Commercial |
$28,781.71
|
| Rate for Payer: HFN Commercial |
$29,751.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,254.25
|
| Rate for Payer: Multiplan Commercial |
$25,871.20
|
| Rate for Payer: NAPHCARE Commercial |
$19,403.40
|
| Rate for Payer: Preferred Network Access Commercial |
$29,751.88
|
| Rate for Payer: Quartz Beloit One Network |
$15,846.11
|
| Rate for Payer: Quartz Commercial |
$21,020.35
|
| Rate for Payer: Quartz Medicare Advantage |
$19,403.40
|
| Rate for Payer: The Alliance Commercial |
$129,356.00
|
| Rate for Payer: WEA Trust Commercial |
$17,786.45
|
| Rate for Payer: WPS Commercial |
$23,953.50
|
|
|
FEMORAL ROTATING HINGE CEMENTED LT X-SMALL S-ROM NOILES 62-3421L
|
Facility
|
IP
|
$32,339.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,846.11 |
| Max. Negotiated Rate |
$29,751.88 |
| Rate for Payer: Aetna Commercial |
$29,105.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27,811.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,139.67
|
| Rate for Payer: Cash Price |
$9,701.70
|
| Rate for Payer: Cigna Commercial |
$29,751.88
|
| Rate for Payer: Health EOS Commercial |
$28,781.71
|
| Rate for Payer: HFN Commercial |
$29,751.88
|
| Rate for Payer: Multiplan Commercial |
$25,871.20
|
| Rate for Payer: NAPHCARE Commercial |
$19,403.40
|
| Rate for Payer: Preferred Network Access Commercial |
$29,751.88
|
| Rate for Payer: Quartz Beloit One Network |
$15,846.11
|
| Rate for Payer: Quartz Commercial |
$19,403.40
|
| Rate for Payer: WEA Trust Commercial |
$17,786.45
|
| Rate for Payer: WPS Commercial |
$23,953.50
|
|
|
FEMORAL ROTATING HINGE NEXGEN CEMENTED RT SZ D 00-5880-014-02
|
Facility
|
IP
|
$41,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192965
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,482.00 |
| Max. Negotiated Rate |
$38,456.00 |
| Rate for Payer: Aetna Commercial |
$37,620.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35,948.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,154.00
|
| Rate for Payer: Cash Price |
$12,540.00
|
| Rate for Payer: Cigna Commercial |
$38,456.00
|
| Rate for Payer: Health EOS Commercial |
$37,202.00
|
| Rate for Payer: HFN Commercial |
$38,456.00
|
| Rate for Payer: Multiplan Commercial |
$33,440.00
|
| Rate for Payer: NAPHCARE Commercial |
$25,080.00
|
| Rate for Payer: Preferred Network Access Commercial |
$38,456.00
|
| Rate for Payer: Quartz Beloit One Network |
$20,482.00
|
| Rate for Payer: Quartz Commercial |
$25,080.00
|
| Rate for Payer: WEA Trust Commercial |
$22,990.00
|
| Rate for Payer: WPS Commercial |
$30,961.26
|
|
|
FEMORAL ROTATING HINGE NEXGEN CEMENTED RT SZ D 00-5880-014-02
|
Facility
|
OP
|
$41,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192965
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,704.00 |
| Max. Negotiated Rate |
$167,200.00 |
| Rate for Payer: Aetna Commercial |
$37,620.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35,948.00
|
| Rate for Payer: Aetna Managed Medicare |
$11,704.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,170.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,900.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,064.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,154.00
|
| Rate for Payer: Cash Price |
$12,540.00
|
| Rate for Payer: Cigna Commercial |
$38,456.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,391.28
|
| Rate for Payer: Health EOS Commercial |
$37,202.00
|
| Rate for Payer: HFN Commercial |
$38,456.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,350.00
|
| Rate for Payer: Multiplan Commercial |
$33,440.00
|
| Rate for Payer: NAPHCARE Commercial |
$25,080.00
|
| Rate for Payer: Preferred Network Access Commercial |
$38,456.00
|
| Rate for Payer: Quartz Beloit One Network |
$20,482.00
|
| Rate for Payer: Quartz Commercial |
$27,170.00
|
| Rate for Payer: Quartz Medicare Advantage |
$25,080.00
|
| Rate for Payer: The Alliance Commercial |
$167,200.00
|
| Rate for Payer: WEA Trust Commercial |
$22,990.00
|
| Rate for Payer: WPS Commercial |
$30,961.26
|
|
|
FEMORAL SIGMA CRUCIATE RETAINTING CEMENTED SZ 6 RT 96-0015
|
Facility
|
OP
|
$6,176.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5803648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,729.28 |
| Max. Negotiated Rate |
$24,704.00 |
| Rate for Payer: Aetna Commercial |
$5,558.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,311.36
|
| Rate for Payer: Aetna Managed Medicare |
$1,729.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,014.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,088.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,964.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,273.28
|
| Rate for Payer: Cash Price |
$1,852.80
|
| Rate for Payer: Cigna Commercial |
$5,681.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,456.09
|
| Rate for Payer: Health EOS Commercial |
$5,496.64
|
| Rate for Payer: HFN Commercial |
$5,681.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,632.00
|
| Rate for Payer: Multiplan Commercial |
$4,940.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,705.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,681.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,026.24
|
| Rate for Payer: Quartz Commercial |
$4,014.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,705.60
|
| Rate for Payer: The Alliance Commercial |
$24,704.00
|
| Rate for Payer: WEA Trust Commercial |
$3,396.80
|
| Rate for Payer: WPS Commercial |
$4,574.56
|
|
|
FEMORAL SIGMA CRUCIATE RETAINTING CEMENTED SZ 6 RT 96-0015
|
Facility
|
IP
|
$6,176.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5803648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,026.24 |
| Max. Negotiated Rate |
$5,681.92 |
| Rate for Payer: Aetna Commercial |
$5,558.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,311.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,273.28
|
| Rate for Payer: Cash Price |
$1,852.80
|
| Rate for Payer: Cigna Commercial |
$5,681.92
|
| Rate for Payer: Health EOS Commercial |
$5,496.64
|
| Rate for Payer: HFN Commercial |
$5,681.92
|
| Rate for Payer: Multiplan Commercial |
$4,940.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,705.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,681.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,026.24
|
| Rate for Payer: Quartz Commercial |
$3,705.60
|
| Rate for Payer: WEA Trust Commercial |
$3,396.80
|
| Rate for Payer: WPS Commercial |
$4,574.56
|
|
|
FEMORAL SLEEVE FULL POROUS ATTUNE 31MM 1294-53-216
|
Facility
|
IP
|
$16,891.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,276.59 |
| Max. Negotiated Rate |
$15,539.72 |
| Rate for Payer: Aetna Commercial |
$15,201.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,526.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,952.23
|
| Rate for Payer: Cash Price |
$5,067.30
|
| Rate for Payer: Cigna Commercial |
$15,539.72
|
| Rate for Payer: Health EOS Commercial |
$15,032.99
|
| Rate for Payer: HFN Commercial |
$15,539.72
|
| Rate for Payer: Multiplan Commercial |
$13,512.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,134.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,539.72
|
| Rate for Payer: Quartz Beloit One Network |
$8,276.59
|
| Rate for Payer: Quartz Commercial |
$10,134.60
|
| Rate for Payer: WEA Trust Commercial |
$9,290.05
|
| Rate for Payer: WPS Commercial |
$12,511.16
|
|
|
FEMORAL SLEEVE FULL POROUS ATTUNE 31MM 1294-53-216
|
Facility
|
OP
|
$16,891.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,729.48 |
| Max. Negotiated Rate |
$67,564.00 |
| Rate for Payer: Aetna Commercial |
$15,201.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,526.26
|
| Rate for Payer: Aetna Managed Medicare |
$4,729.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,979.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,445.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,107.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,952.23
|
| Rate for Payer: Cash Price |
$5,067.30
|
| Rate for Payer: Cigna Commercial |
$15,539.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,452.20
|
| Rate for Payer: Health EOS Commercial |
$15,032.99
|
| Rate for Payer: HFN Commercial |
$15,539.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,668.25
|
| Rate for Payer: Multiplan Commercial |
$13,512.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,134.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,539.72
|
| Rate for Payer: Quartz Beloit One Network |
$8,276.59
|
| Rate for Payer: Quartz Commercial |
$10,979.15
|
| Rate for Payer: Quartz Medicare Advantage |
$10,134.60
|
| Rate for Payer: The Alliance Commercial |
$67,564.00
|
| Rate for Payer: WEA Trust Commercial |
$9,290.05
|
| Rate for Payer: WPS Commercial |
$12,511.16
|
|
|
FEMORAL SLEEVE FULL POROUS ATTUNE 34MM 1294-53-226
|
Facility
|
IP
|
$23,225.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,380.25 |
| Max. Negotiated Rate |
$21,367.00 |
| Rate for Payer: Aetna Commercial |
$20,902.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,973.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,309.25
|
| Rate for Payer: Cash Price |
$6,967.50
|
| Rate for Payer: Cigna Commercial |
$21,367.00
|
| Rate for Payer: Health EOS Commercial |
$20,670.25
|
| Rate for Payer: HFN Commercial |
$21,367.00
|
| Rate for Payer: Multiplan Commercial |
$18,580.00
|
| Rate for Payer: NAPHCARE Commercial |
$13,935.00
|
| Rate for Payer: Preferred Network Access Commercial |
$21,367.00
|
| Rate for Payer: Quartz Beloit One Network |
$11,380.25
|
| Rate for Payer: Quartz Commercial |
$13,935.00
|
| Rate for Payer: WEA Trust Commercial |
$12,773.75
|
| Rate for Payer: WPS Commercial |
$17,202.76
|
|
|
FEMORAL SLEEVE FULL POROUS ATTUNE 34MM 1294-53-226
|
Facility
|
OP
|
$23,225.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,503.00 |
| Max. Negotiated Rate |
$92,900.00 |
| Rate for Payer: Aetna Commercial |
$20,902.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,973.50
|
| Rate for Payer: Aetna Managed Medicare |
$6,503.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,096.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,612.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,148.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,309.25
|
| Rate for Payer: Cash Price |
$6,967.50
|
| Rate for Payer: Cigna Commercial |
$21,367.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,996.71
|
| Rate for Payer: Health EOS Commercial |
$20,670.25
|
| Rate for Payer: HFN Commercial |
$21,367.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,418.75
|
| Rate for Payer: Multiplan Commercial |
$18,580.00
|
| Rate for Payer: NAPHCARE Commercial |
$13,935.00
|
| Rate for Payer: Preferred Network Access Commercial |
$21,367.00
|
| Rate for Payer: Quartz Beloit One Network |
$11,380.25
|
| Rate for Payer: Quartz Commercial |
$15,096.25
|
| Rate for Payer: Quartz Medicare Advantage |
$13,935.00
|
| Rate for Payer: The Alliance Commercial |
$92,900.00
|
| Rate for Payer: WEA Trust Commercial |
$12,773.75
|
| Rate for Payer: WPS Commercial |
$17,202.76
|
|
|
FEMORAL SLEEVE REVISION FULLY COATED ATTUNE 35MM 1511-01-203
|
Facility
|
IP
|
$24,279.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528742
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,896.71 |
| Max. Negotiated Rate |
$22,336.68 |
| Rate for Payer: Aetna Commercial |
$21,851.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,879.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,867.87
|
| Rate for Payer: Cash Price |
$7,283.70
|
| Rate for Payer: Cigna Commercial |
$22,336.68
|
| Rate for Payer: Health EOS Commercial |
$21,608.31
|
| Rate for Payer: HFN Commercial |
$22,336.68
|
| Rate for Payer: Multiplan Commercial |
$19,423.20
|
| Rate for Payer: NAPHCARE Commercial |
$14,567.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22,336.68
|
| Rate for Payer: Quartz Beloit One Network |
$11,896.71
|
| Rate for Payer: Quartz Commercial |
$14,567.40
|
| Rate for Payer: WEA Trust Commercial |
$13,353.45
|
| Rate for Payer: WPS Commercial |
$17,983.46
|
|
|
FEMORAL SLEEVE REVISION FULLY COATED ATTUNE 35MM 1511-01-203
|
Facility
|
OP
|
$24,279.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528742
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,798.12 |
| Max. Negotiated Rate |
$97,116.00 |
| Rate for Payer: Aetna Commercial |
$21,851.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,879.94
|
| Rate for Payer: Aetna Managed Medicare |
$6,798.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,781.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,139.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,653.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,867.87
|
| Rate for Payer: Cash Price |
$7,283.70
|
| Rate for Payer: Cigna Commercial |
$22,336.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,586.53
|
| Rate for Payer: Health EOS Commercial |
$21,608.31
|
| Rate for Payer: HFN Commercial |
$22,336.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,209.25
|
| Rate for Payer: Multiplan Commercial |
$19,423.20
|
| Rate for Payer: NAPHCARE Commercial |
$14,567.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22,336.68
|
| Rate for Payer: Quartz Beloit One Network |
$11,896.71
|
| Rate for Payer: Quartz Commercial |
$15,781.35
|
| Rate for Payer: Quartz Medicare Advantage |
$14,567.40
|
| Rate for Payer: The Alliance Commercial |
$97,116.00
|
| Rate for Payer: WEA Trust Commercial |
$13,353.45
|
| Rate for Payer: WPS Commercial |
$17,983.46
|
|
|
FEMORAL STEM ACTIS DUOFIX SZ 10 12/14 TAPER HIGH COLLAR 1010-12-100
|
Facility
|
IP
|
$11,230.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6178523
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,502.70 |
| Max. Negotiated Rate |
$10,331.60 |
| Rate for Payer: Aetna Commercial |
$10,107.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,657.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,951.90
|
| Rate for Payer: Cash Price |
$3,369.00
|
| Rate for Payer: Cigna Commercial |
$10,331.60
|
| Rate for Payer: Health EOS Commercial |
$9,994.70
|
| Rate for Payer: HFN Commercial |
$10,331.60
|
| Rate for Payer: Multiplan Commercial |
$8,984.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,738.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,331.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,502.70
|
| Rate for Payer: Quartz Commercial |
$6,738.00
|
| Rate for Payer: WEA Trust Commercial |
$6,176.50
|
| Rate for Payer: WPS Commercial |
$8,318.06
|
|
|
FEMORAL STEM ACTIS DUOFIX SZ 10 12/14 TAPER HIGH COLLAR 1010-12-100
|
Facility
|
OP
|
$11,230.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6178523
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,144.40 |
| Max. Negotiated Rate |
$44,920.00 |
| Rate for Payer: Aetna Commercial |
$10,107.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,657.80
|
| Rate for Payer: Aetna Managed Medicare |
$3,144.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,299.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,615.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,390.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,951.90
|
| Rate for Payer: Cash Price |
$3,369.00
|
| Rate for Payer: Cigna Commercial |
$10,331.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,284.31
|
| Rate for Payer: Health EOS Commercial |
$9,994.70
|
| Rate for Payer: HFN Commercial |
$10,331.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,422.50
|
| Rate for Payer: Multiplan Commercial |
$8,984.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,738.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,331.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,502.70
|
| Rate for Payer: Quartz Commercial |
$7,299.50
|
| Rate for Payer: Quartz Medicare Advantage |
$6,738.00
|
| Rate for Payer: The Alliance Commercial |
$44,920.00
|
| Rate for Payer: WEA Trust Commercial |
$6,176.50
|
| Rate for Payer: WPS Commercial |
$8,318.06
|
|
|
FEMORAL STEM ACTIS DUOFIX SZ 2 12/14 TAPER HIGH COLLAR 1010-12-020
|
Facility
|
IP
|
$11,230.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,502.70 |
| Max. Negotiated Rate |
$10,331.60 |
| Rate for Payer: Aetna Commercial |
$10,107.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,657.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,951.90
|
| Rate for Payer: Cash Price |
$3,369.00
|
| Rate for Payer: Cigna Commercial |
$10,331.60
|
| Rate for Payer: Health EOS Commercial |
$9,994.70
|
| Rate for Payer: HFN Commercial |
$10,331.60
|
| Rate for Payer: Multiplan Commercial |
$8,984.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,738.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,331.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,502.70
|
| Rate for Payer: Quartz Commercial |
$6,738.00
|
| Rate for Payer: WEA Trust Commercial |
$6,176.50
|
| Rate for Payer: WPS Commercial |
$8,318.06
|
|
|
FEMORAL STEM ACTIS DUOFIX SZ 2 12/14 TAPER HIGH COLLAR 1010-12-020
|
Facility
|
OP
|
$11,230.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,144.40 |
| Max. Negotiated Rate |
$44,920.00 |
| Rate for Payer: Aetna Commercial |
$10,107.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,657.80
|
| Rate for Payer: Aetna Managed Medicare |
$3,144.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,299.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,615.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,390.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,951.90
|
| Rate for Payer: Cash Price |
$3,369.00
|
| Rate for Payer: Cigna Commercial |
$10,331.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,284.31
|
| Rate for Payer: Health EOS Commercial |
$9,994.70
|
| Rate for Payer: HFN Commercial |
$10,331.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,422.50
|
| Rate for Payer: Multiplan Commercial |
$8,984.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,738.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,331.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,502.70
|
| Rate for Payer: Quartz Commercial |
$7,299.50
|
| Rate for Payer: Quartz Medicare Advantage |
$6,738.00
|
| Rate for Payer: The Alliance Commercial |
$44,920.00
|
| Rate for Payer: WEA Trust Commercial |
$6,176.50
|
| Rate for Payer: WPS Commercial |
$8,318.06
|
|
