|
FEMORAL STEM TRI-LOCK BPS W GRIPTION SZ 4 STD 1012-04-040
|
Facility
|
IP
|
$14,894.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,589.98 |
| Max. Negotiated Rate |
$14,250.58 |
| Rate for Payer: Aetna Commercial |
$13,940.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,321.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,209.57
|
| Rate for Payer: Cash Price |
$4,468.20
|
| Rate for Payer: Cigna Commercial |
$14,250.58
|
| Rate for Payer: Health EOS Commercial |
$13,785.89
|
| Rate for Payer: HFN Commercial |
$14,250.58
|
| Rate for Payer: Multiplan Commercial |
$12,391.81
|
| Rate for Payer: Preferred Network Access Commercial |
$14,250.58
|
| Rate for Payer: Quartz Beloit One Network |
$7,589.98
|
| Rate for Payer: Quartz Commercial |
$9,293.86
|
| Rate for Payer: WEA Trust Commercial |
$8,519.37
|
| Rate for Payer: WPS Commercial |
$11,472.85
|
|
|
FEMORAL STEM TRI-LOCK BPS W GRIPTION SZ 4 STD 1012-04-040
|
Facility
|
OP
|
$14,894.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,337.13 |
| Max. Negotiated Rate |
$14,250.58 |
| Rate for Payer: Aetna Commercial |
$13,940.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,321.19
|
| Rate for Payer: Aetna Managed Medicare |
$4,337.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,068.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,744.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,435.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,209.57
|
| Rate for Payer: Cash Price |
$4,468.20
|
| Rate for Payer: Cigna Commercial |
$14,250.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,668.31
|
| Rate for Payer: Health EOS Commercial |
$13,785.89
|
| Rate for Payer: HFN Commercial |
$14,250.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,617.32
|
| Rate for Payer: Multiplan Commercial |
$12,391.81
|
| Rate for Payer: NAPHCARE Commercial |
$9,293.86
|
| Rate for Payer: Preferred Network Access Commercial |
$14,250.58
|
| Rate for Payer: Quartz Beloit One Network |
$7,589.98
|
| Rate for Payer: Quartz Commercial |
$10,068.34
|
| Rate for Payer: Quartz Medicare Advantage |
$9,293.86
|
| Rate for Payer: The Alliance Commercial |
$7,744.88
|
| Rate for Payer: WEA Trust Commercial |
$8,519.37
|
| Rate for Payer: WPS Commercial |
$11,472.85
|
|
|
FEMORAL STEM TRI-LOCK BPS W GRIPTION SZ 8 STD 1012-04-080
|
Facility
|
OP
|
$16,085.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520884
|
|
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 TRI-LOCK BPS W GRIPTION SZ 8 STD 1012-04-080
|
Facility
|
IP
|
$16,085.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520884
|
|
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 VERSYS FULLCOAT SZ 11 7843-11-06
|
Facility
|
IP
|
$21,094.00
|
|
| Hospital Charge Code |
2967482
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,749.50 |
| Max. Negotiated Rate |
$20,182.74 |
| Rate for Payer: Aetna Commercial |
$19,743.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,866.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,627.01
|
| Rate for Payer: Cash Price |
$6,328.20
|
| Rate for Payer: Cigna Commercial |
$20,182.74
|
| Rate for Payer: Health EOS Commercial |
$19,524.61
|
| Rate for Payer: HFN Commercial |
$20,182.74
|
| Rate for Payer: Multiplan Commercial |
$17,550.21
|
| Rate for Payer: Preferred Network Access Commercial |
$20,182.74
|
| Rate for Payer: Quartz Beloit One Network |
$10,749.50
|
| Rate for Payer: Quartz Commercial |
$13,162.66
|
| Rate for Payer: WEA Trust Commercial |
$12,065.77
|
| Rate for Payer: WPS Commercial |
$16,248.71
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 11 7843-11-06
|
Facility
|
OP
|
$21,094.00
|
|
| Hospital Charge Code |
2967482
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,142.57 |
| Max. Negotiated Rate |
$20,182.74 |
| Rate for Payer: Aetna Commercial |
$19,743.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,866.47
|
| Rate for Payer: Aetna Managed Medicare |
$6,142.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,259.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,968.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,530.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,627.01
|
| Rate for Payer: Cash Price |
$6,328.20
|
| Rate for Payer: Cigna Commercial |
$20,182.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,276.71
|
| Rate for Payer: Health EOS Commercial |
$19,524.61
|
| Rate for Payer: HFN Commercial |
$20,182.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,453.32
|
| Rate for Payer: Multiplan Commercial |
$17,550.21
|
| Rate for Payer: NAPHCARE Commercial |
$13,162.66
|
| Rate for Payer: Preferred Network Access Commercial |
$20,182.74
|
| Rate for Payer: Quartz Beloit One Network |
$10,749.50
|
| Rate for Payer: Quartz Commercial |
$14,259.54
|
| Rate for Payer: Quartz Medicare Advantage |
$13,162.66
|
| Rate for Payer: The Alliance Commercial |
$10,968.88
|
| Rate for Payer: WEA Trust Commercial |
$12,065.77
|
| Rate for Payer: WPS Commercial |
$16,248.71
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 13.5 X 200 LT 7843-13-81
|
Facility
|
IP
|
$41,801.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,301.79 |
| Max. Negotiated Rate |
$39,995.20 |
| Rate for Payer: Aetna Commercial |
$39,125.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37,386.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,040.71
|
| Rate for Payer: Cash Price |
$12,540.30
|
| Rate for Payer: Cigna Commercial |
$39,995.20
|
| Rate for Payer: Health EOS Commercial |
$38,691.01
|
| Rate for Payer: HFN Commercial |
$39,995.20
|
| Rate for Payer: Multiplan Commercial |
$34,778.43
|
| Rate for Payer: Preferred Network Access Commercial |
$39,995.20
|
| Rate for Payer: Quartz Beloit One Network |
$21,301.79
|
| Rate for Payer: Quartz Commercial |
$26,083.82
|
| Rate for Payer: WEA Trust Commercial |
$23,910.17
|
| Rate for Payer: WPS Commercial |
$32,199.31
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 13.5 X 200 LT 7843-13-81
|
Facility
|
OP
|
$41,801.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,172.45 |
| Max. Negotiated Rate |
$39,995.20 |
| Rate for Payer: Aetna Commercial |
$39,125.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37,386.81
|
| Rate for Payer: Aetna Managed Medicare |
$12,172.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,257.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,736.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,867.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,040.71
|
| Rate for Payer: Cash Price |
$12,540.30
|
| Rate for Payer: Cigna Commercial |
$39,995.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,328.18
|
| Rate for Payer: Health EOS Commercial |
$38,691.01
|
| Rate for Payer: HFN Commercial |
$39,995.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,604.78
|
| Rate for Payer: Multiplan Commercial |
$34,778.43
|
| Rate for Payer: NAPHCARE Commercial |
$26,083.82
|
| Rate for Payer: Preferred Network Access Commercial |
$39,995.20
|
| Rate for Payer: Quartz Beloit One Network |
$21,301.79
|
| Rate for Payer: Quartz Commercial |
$28,257.48
|
| Rate for Payer: Quartz Medicare Advantage |
$26,083.82
|
| Rate for Payer: The Alliance Commercial |
$21,736.52
|
| Rate for Payer: WEA Trust Commercial |
$23,910.17
|
| Rate for Payer: WPS Commercial |
$32,199.31
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 13 STD 7843-13-06
|
Facility
|
OP
|
$21,271.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967480
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,194.12 |
| Max. Negotiated Rate |
$20,352.09 |
| Rate for Payer: Aetna Commercial |
$19,909.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,024.78
|
| Rate for Payer: Aetna Managed Medicare |
$6,194.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,379.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,060.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,618.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,724.58
|
| Rate for Payer: Cash Price |
$6,381.30
|
| Rate for Payer: Cigna Commercial |
$20,352.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,379.72
|
| Rate for Payer: Health EOS Commercial |
$19,688.44
|
| Rate for Payer: HFN Commercial |
$20,352.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,591.38
|
| Rate for Payer: Multiplan Commercial |
$17,697.47
|
| Rate for Payer: NAPHCARE Commercial |
$13,273.10
|
| Rate for Payer: Preferred Network Access Commercial |
$20,352.09
|
| Rate for Payer: Quartz Beloit One Network |
$10,839.70
|
| Rate for Payer: Quartz Commercial |
$14,379.20
|
| Rate for Payer: Quartz Medicare Advantage |
$13,273.10
|
| Rate for Payer: The Alliance Commercial |
$11,060.92
|
| Rate for Payer: WEA Trust Commercial |
$12,167.01
|
| Rate for Payer: WPS Commercial |
$16,385.05
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 13 STD 7843-13-06
|
Facility
|
IP
|
$21,271.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967480
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,839.70 |
| Max. Negotiated Rate |
$20,352.09 |
| Rate for Payer: Aetna Commercial |
$19,909.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,024.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,724.58
|
| Rate for Payer: Cash Price |
$6,381.30
|
| Rate for Payer: Cigna Commercial |
$20,352.09
|
| Rate for Payer: Health EOS Commercial |
$19,688.44
|
| Rate for Payer: HFN Commercial |
$20,352.09
|
| Rate for Payer: Multiplan Commercial |
$17,697.47
|
| Rate for Payer: Preferred Network Access Commercial |
$20,352.09
|
| Rate for Payer: Quartz Beloit One Network |
$10,839.70
|
| Rate for Payer: Quartz Commercial |
$13,273.10
|
| Rate for Payer: WEA Trust Commercial |
$12,167.01
|
| Rate for Payer: WPS Commercial |
$16,385.05
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 14 7843-14-36
|
Facility
|
OP
|
$23,528.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967537
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,851.35 |
| Max. Negotiated Rate |
$22,511.59 |
| Rate for Payer: Aetna Commercial |
$22,022.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,043.44
|
| Rate for Payer: Aetna Managed Medicare |
$6,851.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,904.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,234.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,745.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,968.63
|
| Rate for Payer: Cash Price |
$7,058.40
|
| Rate for Payer: Cigna Commercial |
$22,511.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,693.30
|
| Rate for Payer: Health EOS Commercial |
$21,777.52
|
| Rate for Payer: HFN Commercial |
$22,511.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,351.84
|
| Rate for Payer: Multiplan Commercial |
$19,575.30
|
| Rate for Payer: NAPHCARE Commercial |
$14,681.47
|
| Rate for Payer: Preferred Network Access Commercial |
$22,511.59
|
| Rate for Payer: Quartz Beloit One Network |
$11,989.87
|
| Rate for Payer: Quartz Commercial |
$15,904.93
|
| Rate for Payer: Quartz Medicare Advantage |
$14,681.47
|
| Rate for Payer: The Alliance Commercial |
$12,234.56
|
| Rate for Payer: WEA Trust Commercial |
$13,458.02
|
| Rate for Payer: WPS Commercial |
$18,123.62
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 14 7843-14-36
|
Facility
|
IP
|
$23,528.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967537
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,989.87 |
| Max. Negotiated Rate |
$22,511.59 |
| Rate for Payer: Aetna Commercial |
$22,022.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,043.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,968.63
|
| Rate for Payer: Cash Price |
$7,058.40
|
| Rate for Payer: Cigna Commercial |
$22,511.59
|
| Rate for Payer: Health EOS Commercial |
$21,777.52
|
| Rate for Payer: HFN Commercial |
$22,511.59
|
| Rate for Payer: Multiplan Commercial |
$19,575.30
|
| Rate for Payer: Preferred Network Access Commercial |
$22,511.59
|
| Rate for Payer: Quartz Beloit One Network |
$11,989.87
|
| Rate for Payer: Quartz Commercial |
$14,681.47
|
| Rate for Payer: WEA Trust Commercial |
$13,458.02
|
| Rate for Payer: WPS Commercial |
$18,123.62
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 15 7843-15-36
|
Facility
|
IP
|
$25,105.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,793.51 |
| Max. Negotiated Rate |
$24,020.46 |
| Rate for Payer: Aetna Commercial |
$23,498.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,453.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,837.88
|
| Rate for Payer: Cash Price |
$7,531.50
|
| Rate for Payer: Cigna Commercial |
$24,020.46
|
| Rate for Payer: Health EOS Commercial |
$23,237.19
|
| Rate for Payer: HFN Commercial |
$24,020.46
|
| Rate for Payer: Multiplan Commercial |
$20,887.36
|
| Rate for Payer: Preferred Network Access Commercial |
$24,020.46
|
| Rate for Payer: Quartz Beloit One Network |
$12,793.51
|
| Rate for Payer: Quartz Commercial |
$15,665.52
|
| Rate for Payer: WEA Trust Commercial |
$14,360.06
|
| Rate for Payer: WPS Commercial |
$19,338.38
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 15 7843-15-36
|
Facility
|
OP
|
$25,105.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967536
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,310.58 |
| Max. Negotiated Rate |
$24,020.46 |
| Rate for Payer: Aetna Commercial |
$23,498.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,453.91
|
| Rate for Payer: Aetna Managed Medicare |
$7,310.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,970.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,054.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,532.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,837.88
|
| Rate for Payer: Cash Price |
$7,531.50
|
| Rate for Payer: Cigna Commercial |
$24,020.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,611.11
|
| Rate for Payer: Health EOS Commercial |
$23,237.19
|
| Rate for Payer: HFN Commercial |
$24,020.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,581.90
|
| Rate for Payer: Multiplan Commercial |
$20,887.36
|
| Rate for Payer: NAPHCARE Commercial |
$15,665.52
|
| Rate for Payer: Preferred Network Access Commercial |
$24,020.46
|
| Rate for Payer: Quartz Beloit One Network |
$12,793.51
|
| Rate for Payer: Quartz Commercial |
$16,970.98
|
| Rate for Payer: Quartz Medicare Advantage |
$15,665.52
|
| Rate for Payer: The Alliance Commercial |
$13,054.60
|
| Rate for Payer: WEA Trust Commercial |
$14,360.06
|
| Rate for Payer: WPS Commercial |
$19,338.38
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 15 STD 7843-15-06
|
Facility
|
OP
|
$24,328.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,084.31 |
| Max. Negotiated Rate |
$23,277.03 |
| Rate for Payer: Aetna Commercial |
$22,771.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,758.96
|
| Rate for Payer: Aetna Managed Medicare |
$7,084.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,445.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,650.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,144.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,409.59
|
| Rate for Payer: Cash Price |
$7,298.40
|
| Rate for Payer: Cigna Commercial |
$23,277.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,158.90
|
| Rate for Payer: Health EOS Commercial |
$22,518.00
|
| Rate for Payer: HFN Commercial |
$23,277.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,975.84
|
| Rate for Payer: Multiplan Commercial |
$20,240.90
|
| Rate for Payer: NAPHCARE Commercial |
$15,180.67
|
| Rate for Payer: Preferred Network Access Commercial |
$23,277.03
|
| Rate for Payer: Quartz Beloit One Network |
$12,397.55
|
| Rate for Payer: Quartz Commercial |
$16,445.73
|
| Rate for Payer: Quartz Medicare Advantage |
$15,180.67
|
| Rate for Payer: The Alliance Commercial |
$12,650.56
|
| Rate for Payer: WEA Trust Commercial |
$13,915.62
|
| Rate for Payer: WPS Commercial |
$18,739.86
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 15 STD 7843-15-06
|
Facility
|
IP
|
$24,328.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,397.55 |
| Max. Negotiated Rate |
$23,277.03 |
| Rate for Payer: Aetna Commercial |
$22,771.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,758.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,409.59
|
| Rate for Payer: Cash Price |
$7,298.40
|
| Rate for Payer: Cigna Commercial |
$23,277.03
|
| Rate for Payer: Health EOS Commercial |
$22,518.00
|
| Rate for Payer: HFN Commercial |
$23,277.03
|
| Rate for Payer: Multiplan Commercial |
$20,240.90
|
| Rate for Payer: Preferred Network Access Commercial |
$23,277.03
|
| Rate for Payer: Quartz Beloit One Network |
$12,397.55
|
| Rate for Payer: Quartz Commercial |
$15,180.67
|
| Rate for Payer: WEA Trust Commercial |
$13,915.62
|
| Rate for Payer: WPS Commercial |
$18,739.86
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 16.5 7843-16-18
|
Facility
|
OP
|
$43,246.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,593.24 |
| Max. Negotiated Rate |
$41,377.77 |
| Rate for Payer: Aetna Commercial |
$40,478.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38,679.22
|
| Rate for Payer: Aetna Managed Medicare |
$12,593.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,234.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,487.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,588.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,837.20
|
| Rate for Payer: Cash Price |
$12,973.80
|
| Rate for Payer: Cigna Commercial |
$41,377.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,169.17
|
| Rate for Payer: Health EOS Commercial |
$40,028.50
|
| Rate for Payer: HFN Commercial |
$41,377.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33,731.88
|
| Rate for Payer: Multiplan Commercial |
$35,980.67
|
| Rate for Payer: NAPHCARE Commercial |
$26,985.50
|
| Rate for Payer: Preferred Network Access Commercial |
$41,377.77
|
| Rate for Payer: Quartz Beloit One Network |
$22,038.16
|
| Rate for Payer: Quartz Commercial |
$29,234.30
|
| Rate for Payer: Quartz Medicare Advantage |
$26,985.50
|
| Rate for Payer: The Alliance Commercial |
$22,487.92
|
| Rate for Payer: WEA Trust Commercial |
$24,736.71
|
| Rate for Payer: WPS Commercial |
$33,312.39
|
|
|
FEMORAL STEM VERSYS FULLCOAT SZ 16.5 7843-16-18
|
Facility
|
IP
|
$43,246.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,038.16 |
| Max. Negotiated Rate |
$41,377.77 |
| Rate for Payer: Aetna Commercial |
$40,478.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38,679.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,837.20
|
| Rate for Payer: Cash Price |
$12,973.80
|
| Rate for Payer: Cigna Commercial |
$41,377.77
|
| Rate for Payer: Health EOS Commercial |
$40,028.50
|
| Rate for Payer: HFN Commercial |
$41,377.77
|
| Rate for Payer: Multiplan Commercial |
$35,980.67
|
| Rate for Payer: Preferred Network Access Commercial |
$41,377.77
|
| Rate for Payer: Quartz Beloit One Network |
$22,038.16
|
| Rate for Payer: Quartz Commercial |
$26,985.50
|
| Rate for Payer: WEA Trust Commercial |
$24,736.71
|
| Rate for Payer: WPS Commercial |
$33,312.39
|
|
|
FEMORAL TC3 SIGMA CEMENTED SZ 3 RT 96-0088
|
Facility
|
IP
|
$46,595.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$23,744.81 |
| Max. Negotiated Rate |
$44,582.10 |
| Rate for Payer: Aetna Commercial |
$43,612.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41,674.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25,683.16
|
| Rate for Payer: Cash Price |
$13,978.50
|
| Rate for Payer: Cigna Commercial |
$44,582.10
|
| Rate for Payer: Health EOS Commercial |
$43,128.33
|
| Rate for Payer: HFN Commercial |
$44,582.10
|
| Rate for Payer: Multiplan Commercial |
$38,767.04
|
| Rate for Payer: Preferred Network Access Commercial |
$44,582.10
|
| Rate for Payer: Quartz Beloit One Network |
$23,744.81
|
| Rate for Payer: Quartz Commercial |
$29,075.28
|
| Rate for Payer: WEA Trust Commercial |
$26,652.34
|
| Rate for Payer: WPS Commercial |
$35,892.13
|
|
|
FEMORAL TC3 SIGMA CEMENTED SZ 3 RT 96-0088
|
Facility
|
OP
|
$46,595.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,568.46 |
| Max. Negotiated Rate |
$44,582.10 |
| Rate for Payer: Aetna Commercial |
$43,612.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41,674.57
|
| Rate for Payer: Aetna Managed Medicare |
$13,568.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,498.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,229.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,260.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25,683.16
|
| Rate for Payer: Cash Price |
$13,978.50
|
| Rate for Payer: Cigna Commercial |
$44,582.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,118.29
|
| Rate for Payer: Health EOS Commercial |
$43,128.33
|
| Rate for Payer: HFN Commercial |
$44,582.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36,344.10
|
| Rate for Payer: Multiplan Commercial |
$38,767.04
|
| Rate for Payer: NAPHCARE Commercial |
$29,075.28
|
| Rate for Payer: Preferred Network Access Commercial |
$44,582.10
|
| Rate for Payer: Quartz Beloit One Network |
$23,744.81
|
| Rate for Payer: Quartz Commercial |
$31,498.22
|
| Rate for Payer: Quartz Medicare Advantage |
$29,075.28
|
| Rate for Payer: The Alliance Commercial |
$24,229.40
|
| Rate for Payer: WEA Trust Commercial |
$26,652.34
|
| Rate for Payer: WPS Commercial |
$35,892.13
|
|
|
FEMORAL TROCHLEA 20mm OFFSET
|
Facility
|
OP
|
$24,667.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2964729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,183.03 |
| Max. Negotiated Rate |
$23,601.39 |
| Rate for Payer: Aetna Commercial |
$23,088.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,062.16
|
| Rate for Payer: Aetna Managed Medicare |
$7,183.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,674.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,826.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,313.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,596.45
|
| Rate for Payer: Cash Price |
$7,400.10
|
| Rate for Payer: Cigna Commercial |
$23,601.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,356.19
|
| Rate for Payer: Health EOS Commercial |
$22,831.78
|
| Rate for Payer: HFN Commercial |
$23,601.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,240.26
|
| Rate for Payer: Multiplan Commercial |
$20,522.94
|
| Rate for Payer: NAPHCARE Commercial |
$15,392.21
|
| Rate for Payer: Preferred Network Access Commercial |
$23,601.39
|
| Rate for Payer: Quartz Beloit One Network |
$12,570.30
|
| Rate for Payer: Quartz Commercial |
$16,674.89
|
| Rate for Payer: Quartz Medicare Advantage |
$15,392.21
|
| Rate for Payer: The Alliance Commercial |
$12,826.84
|
| Rate for Payer: WEA Trust Commercial |
$14,109.52
|
| Rate for Payer: WPS Commercial |
$19,000.99
|
|
|
FEMORAL TROCHLEA 20mm OFFSET
|
Facility
|
IP
|
$24,667.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2964729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,570.30 |
| Max. Negotiated Rate |
$23,601.39 |
| Rate for Payer: Aetna Commercial |
$23,088.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,062.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,596.45
|
| Rate for Payer: Cash Price |
$7,400.10
|
| Rate for Payer: Cigna Commercial |
$23,601.39
|
| Rate for Payer: Health EOS Commercial |
$22,831.78
|
| Rate for Payer: HFN Commercial |
$23,601.39
|
| Rate for Payer: Multiplan Commercial |
$20,522.94
|
| Rate for Payer: Preferred Network Access Commercial |
$23,601.39
|
| Rate for Payer: Quartz Beloit One Network |
$12,570.30
|
| Rate for Payer: Quartz Commercial |
$15,392.21
|
| Rate for Payer: WEA Trust Commercial |
$14,109.52
|
| Rate for Payer: WPS Commercial |
$19,000.99
|
|
|
FEMSTOP HD CLOSURE DEVICE #C11165
|
Facility
|
OP
|
$1,061.00
|
|
|
Service Code
|
HCPCS C1760
|
| Hospital Charge Code |
2973764
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$308.96 |
| Max. Negotiated Rate |
$1,015.16 |
| Rate for Payer: Aetna Commercial |
$993.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.96
|
| Rate for Payer: Aetna Managed Medicare |
$308.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$717.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$551.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$529.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.82
|
| Rate for Payer: Cash Price |
$318.30
|
| Rate for Payer: Cigna Commercial |
$1,015.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$617.50
|
| Rate for Payer: Health EOS Commercial |
$982.06
|
| Rate for Payer: HFN Commercial |
$1,015.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$827.58
|
| Rate for Payer: Multiplan Commercial |
$882.75
|
| Rate for Payer: NAPHCARE Commercial |
$662.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,015.16
|
| Rate for Payer: Quartz Beloit One Network |
$540.69
|
| Rate for Payer: Quartz Commercial |
$717.24
|
| Rate for Payer: Quartz Medicare Advantage |
$662.06
|
| Rate for Payer: The Alliance Commercial |
$551.72
|
| Rate for Payer: WEA Trust Commercial |
$606.89
|
| Rate for Payer: WPS Commercial |
$817.29
|
|
|
FEMSTOP HD CLOSURE DEVICE #C11165
|
Facility
|
IP
|
$1,061.00
|
|
|
Service Code
|
HCPCS C1760
|
| Hospital Charge Code |
2973764
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$540.69 |
| Max. Negotiated Rate |
$1,015.16 |
| Rate for Payer: Aetna Commercial |
$993.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$948.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$584.82
|
| Rate for Payer: Cash Price |
$318.30
|
| Rate for Payer: Cigna Commercial |
$1,015.16
|
| Rate for Payer: Health EOS Commercial |
$982.06
|
| Rate for Payer: HFN Commercial |
$1,015.16
|
| Rate for Payer: Multiplan Commercial |
$882.75
|
| Rate for Payer: Preferred Network Access Commercial |
$1,015.16
|
| Rate for Payer: Quartz Beloit One Network |
$540.69
|
| Rate for Payer: Quartz Commercial |
$662.06
|
| Rate for Payer: WEA Trust Commercial |
$606.89
|
| Rate for Payer: WPS Commercial |
$817.29
|
|
|
FEMUR BONE GRAFTING
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2959858
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,214.30 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,214.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,818.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,168.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,081.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,426.94
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,252.60
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,602.08
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,818.92
|
| Rate for Payer: Quartz Medicare Advantage |
$2,602.08
|
| Rate for Payer: The Alliance Commercial |
$2,168.40
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
