|
FEMORAL STEM TAPERLOC STD OFFSET SZ 12 X 144MM 51-103120
|
Facility
|
IP
|
$12,612.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,179.88 |
| Max. Negotiated Rate |
$11,603.04 |
| Rate for Payer: Aetna Commercial |
$11,350.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,846.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,684.36
|
| Rate for Payer: Cash Price |
$3,783.60
|
| Rate for Payer: Cigna Commercial |
$11,603.04
|
| Rate for Payer: Health EOS Commercial |
$11,224.68
|
| Rate for Payer: HFN Commercial |
$11,603.04
|
| Rate for Payer: Multiplan Commercial |
$10,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,567.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,603.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,179.88
|
| Rate for Payer: Quartz Commercial |
$7,567.20
|
| Rate for Payer: WEA Trust Commercial |
$6,936.60
|
| Rate for Payer: WPS Commercial |
$9,341.71
|
|
|
FEMORAL STEM TAPERLOC STD OFFSET SZ 17 X 154MM 51-103170
|
Facility
|
OP
|
$12,612.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,531.36 |
| Max. Negotiated Rate |
$50,448.00 |
| Rate for Payer: Aetna Commercial |
$11,350.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,846.32
|
| Rate for Payer: Aetna Managed Medicare |
$3,531.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,197.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,306.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,053.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,684.36
|
| Rate for Payer: Cash Price |
$3,783.60
|
| Rate for Payer: Cigna Commercial |
$11,603.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,057.68
|
| Rate for Payer: Health EOS Commercial |
$11,224.68
|
| Rate for Payer: HFN Commercial |
$11,603.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,459.00
|
| Rate for Payer: Multiplan Commercial |
$10,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,567.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,603.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,179.88
|
| Rate for Payer: Quartz Commercial |
$8,197.80
|
| Rate for Payer: Quartz Medicare Advantage |
$7,567.20
|
| Rate for Payer: The Alliance Commercial |
$50,448.00
|
| Rate for Payer: WEA Trust Commercial |
$6,936.60
|
| Rate for Payer: WPS Commercial |
$9,341.71
|
|
|
FEMORAL STEM TAPERLOC STD OFFSET SZ 17 X 154MM 51-103170
|
Facility
|
IP
|
$12,612.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,179.88 |
| Max. Negotiated Rate |
$11,603.04 |
| Rate for Payer: Aetna Commercial |
$11,350.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,846.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,684.36
|
| Rate for Payer: Cash Price |
$3,783.60
|
| Rate for Payer: Cigna Commercial |
$11,603.04
|
| Rate for Payer: Health EOS Commercial |
$11,224.68
|
| Rate for Payer: HFN Commercial |
$11,603.04
|
| Rate for Payer: Multiplan Commercial |
$10,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,567.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,603.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,179.88
|
| Rate for Payer: Quartz Commercial |
$7,567.20
|
| Rate for Payer: WEA Trust Commercial |
$6,936.60
|
| Rate for Payer: WPS Commercial |
$9,341.71
|
|
|
FEMORAL STEM TRABECULAR METAL 13MM STD OFFSET 00-7864-013-00
|
Facility
|
IP
|
$26,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,804.19 |
| Max. Negotiated Rate |
$24,040.52 |
| Rate for Payer: Aetna Commercial |
$23,517.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,472.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,849.43
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$24,040.52
|
| Rate for Payer: Health EOS Commercial |
$23,256.59
|
| Rate for Payer: HFN Commercial |
$24,040.52
|
| Rate for Payer: Multiplan Commercial |
$20,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,678.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,040.52
|
| Rate for Payer: Quartz Beloit One Network |
$12,804.19
|
| Rate for Payer: Quartz Commercial |
$15,678.60
|
| Rate for Payer: WEA Trust Commercial |
$14,372.05
|
| Rate for Payer: WPS Commercial |
$19,355.23
|
|
|
FEMORAL STEM TRABECULAR METAL 13MM STD OFFSET 00-7864-013-00
|
Facility
|
OP
|
$26,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,316.68 |
| Max. Negotiated Rate |
$104,524.00 |
| Rate for Payer: Aetna Commercial |
$23,517.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,472.66
|
| Rate for Payer: Aetna Managed Medicare |
$7,316.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,985.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,065.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,542.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,849.43
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$24,040.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,622.91
|
| Rate for Payer: Health EOS Commercial |
$23,256.59
|
| Rate for Payer: HFN Commercial |
$24,040.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,598.25
|
| Rate for Payer: Multiplan Commercial |
$20,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,678.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,040.52
|
| Rate for Payer: Quartz Beloit One Network |
$12,804.19
|
| Rate for Payer: Quartz Commercial |
$16,985.15
|
| Rate for Payer: Quartz Medicare Advantage |
$15,678.60
|
| Rate for Payer: The Alliance Commercial |
$104,524.00
|
| Rate for Payer: WEA Trust Commercial |
$14,372.05
|
| Rate for Payer: WPS Commercial |
$19,355.23
|
|
|
FEMORAL STEM TRABECULAR METAL STD NECK OFFSET 11MM 00-7864-011-00
|
Facility
|
OP
|
$26,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967842
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,316.68 |
| Max. Negotiated Rate |
$104,524.00 |
| Rate for Payer: Aetna Commercial |
$23,517.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,472.66
|
| Rate for Payer: Aetna Managed Medicare |
$7,316.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,985.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,065.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,542.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,849.43
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$24,040.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,622.91
|
| Rate for Payer: Health EOS Commercial |
$23,256.59
|
| Rate for Payer: HFN Commercial |
$24,040.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,598.25
|
| Rate for Payer: Multiplan Commercial |
$20,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,678.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,040.52
|
| Rate for Payer: Quartz Beloit One Network |
$12,804.19
|
| Rate for Payer: Quartz Commercial |
$16,985.15
|
| Rate for Payer: Quartz Medicare Advantage |
$15,678.60
|
| Rate for Payer: The Alliance Commercial |
$104,524.00
|
| Rate for Payer: WEA Trust Commercial |
$14,372.05
|
| Rate for Payer: WPS Commercial |
$19,355.23
|
|
|
FEMORAL STEM TRABECULAR METAL STD NECK OFFSET 11MM 00-7864-011-00
|
Facility
|
IP
|
$26,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967842
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,804.19 |
| Max. Negotiated Rate |
$24,040.52 |
| Rate for Payer: Aetna Commercial |
$23,517.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,472.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,849.43
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$24,040.52
|
| Rate for Payer: Health EOS Commercial |
$23,256.59
|
| Rate for Payer: HFN Commercial |
$24,040.52
|
| Rate for Payer: Multiplan Commercial |
$20,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,678.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,040.52
|
| Rate for Payer: Quartz Beloit One Network |
$12,804.19
|
| Rate for Payer: Quartz Commercial |
$15,678.60
|
| Rate for Payer: WEA Trust Commercial |
$14,372.05
|
| Rate for Payer: WPS Commercial |
$19,355.23
|
|
|
FEMORAL STEM TRABECULAR METAL STD OFFSET 12MM 00-7864-012-00
|
Facility
|
IP
|
$26,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967844
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,804.19 |
| Max. Negotiated Rate |
$24,040.52 |
| Rate for Payer: Aetna Commercial |
$23,517.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,472.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,849.43
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$24,040.52
|
| Rate for Payer: Health EOS Commercial |
$23,256.59
|
| Rate for Payer: HFN Commercial |
$24,040.52
|
| Rate for Payer: Multiplan Commercial |
$20,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,678.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,040.52
|
| Rate for Payer: Quartz Beloit One Network |
$12,804.19
|
| Rate for Payer: Quartz Commercial |
$15,678.60
|
| Rate for Payer: WEA Trust Commercial |
$14,372.05
|
| Rate for Payer: WPS Commercial |
$19,355.23
|
|
|
FEMORAL STEM TRABECULAR METAL STD OFFSET 12MM 00-7864-012-00
|
Facility
|
OP
|
$26,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967844
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,316.68 |
| Max. Negotiated Rate |
$104,524.00 |
| Rate for Payer: Aetna Commercial |
$23,517.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,472.66
|
| Rate for Payer: Aetna Managed Medicare |
$7,316.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,985.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,065.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,542.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,849.43
|
| Rate for Payer: Cash Price |
$7,839.30
|
| Rate for Payer: Cigna Commercial |
$24,040.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,622.91
|
| Rate for Payer: Health EOS Commercial |
$23,256.59
|
| Rate for Payer: HFN Commercial |
$24,040.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,598.25
|
| Rate for Payer: Multiplan Commercial |
$20,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,678.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,040.52
|
| Rate for Payer: Quartz Beloit One Network |
$12,804.19
|
| Rate for Payer: Quartz Commercial |
$16,985.15
|
| Rate for Payer: Quartz Medicare Advantage |
$15,678.60
|
| Rate for Payer: The Alliance Commercial |
$104,524.00
|
| Rate for Payer: WEA Trust Commercial |
$14,372.05
|
| Rate for Payer: WPS Commercial |
$19,355.23
|
|
|
FEMORAL STEM TRI-LOCK BPS W GRIPTION SZ 2 STD 1012-04-020
|
Facility
|
OP
|
$14,894.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563226
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,170.32 |
| Max. Negotiated Rate |
$59,576.00 |
| Rate for Payer: Aetna Commercial |
$13,404.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,808.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,170.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,681.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,447.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,149.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,893.82
|
| Rate for Payer: Cash Price |
$4,468.20
|
| Rate for Payer: Cigna Commercial |
$13,702.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,334.68
|
| Rate for Payer: Health EOS Commercial |
$13,255.66
|
| Rate for Payer: HFN Commercial |
$13,702.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,170.50
|
| Rate for Payer: Multiplan Commercial |
$11,915.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,936.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,702.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,298.06
|
| Rate for Payer: Quartz Commercial |
$9,681.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8,936.40
|
| Rate for Payer: The Alliance Commercial |
$59,576.00
|
| Rate for Payer: WEA Trust Commercial |
$8,191.70
|
| Rate for Payer: WPS Commercial |
$11,031.99
|
|
|
FEMORAL STEM TRI-LOCK BPS W GRIPTION SZ 2 STD 1012-04-020
|
Facility
|
IP
|
$14,894.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563226
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,298.06 |
| Max. Negotiated Rate |
$13,702.48 |
| Rate for Payer: Aetna Commercial |
$13,404.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,808.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,893.82
|
| Rate for Payer: Cash Price |
$4,468.20
|
| Rate for Payer: Cigna Commercial |
$13,702.48
|
| Rate for Payer: Health EOS Commercial |
$13,255.66
|
| Rate for Payer: HFN Commercial |
$13,702.48
|
| Rate for Payer: Multiplan Commercial |
$11,915.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,936.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,702.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,298.06
|
| Rate for Payer: Quartz Commercial |
$8,936.40
|
| Rate for Payer: WEA Trust Commercial |
$8,191.70
|
| Rate for Payer: WPS Commercial |
$11,031.99
|
|
|
FEMORAL STEM TRI-LOCK BPS W GRIPTION SZ 3 STD 1012-04-030
|
Facility
|
IP
|
$15,490.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5497005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,590.10 |
| Max. Negotiated Rate |
$14,250.80 |
| Rate for Payer: Aetna Commercial |
$13,941.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,321.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,209.70
|
| Rate for Payer: Cash Price |
$4,647.00
|
| Rate for Payer: Cigna Commercial |
$14,250.80
|
| Rate for Payer: Health EOS Commercial |
$13,786.10
|
| Rate for Payer: HFN Commercial |
$14,250.80
|
| Rate for Payer: Multiplan Commercial |
$12,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,294.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,250.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,590.10
|
| Rate for Payer: Quartz Commercial |
$9,294.00
|
| Rate for Payer: WEA Trust Commercial |
$8,519.50
|
| Rate for Payer: WPS Commercial |
$11,473.44
|
|
|
FEMORAL STEM TRI-LOCK BPS W GRIPTION SZ 3 STD 1012-04-030
|
Facility
|
OP
|
$15,490.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5497005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,337.20 |
| Max. Negotiated Rate |
$61,960.00 |
| Rate for Payer: Aetna Commercial |
$13,941.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,321.40
|
| Rate for Payer: Aetna Managed Medicare |
$4,337.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,068.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,745.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,435.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,209.70
|
| Rate for Payer: Cash Price |
$4,647.00
|
| Rate for Payer: Cigna Commercial |
$14,250.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,668.20
|
| Rate for Payer: Health EOS Commercial |
$13,786.10
|
| Rate for Payer: HFN Commercial |
$14,250.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,617.50
|
| Rate for Payer: Multiplan Commercial |
$12,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,294.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,250.80
|
| Rate for Payer: Quartz Beloit One Network |
$7,590.10
|
| Rate for Payer: Quartz Commercial |
$10,068.50
|
| Rate for Payer: Quartz Medicare Advantage |
$9,294.00
|
| Rate for Payer: The Alliance Commercial |
$61,960.00
|
| Rate for Payer: WEA Trust Commercial |
$8,519.50
|
| Rate for Payer: WPS Commercial |
$11,473.44
|
|
|
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 |
$4,170.32 |
| Max. Negotiated Rate |
$59,576.00 |
| Rate for Payer: Aetna Commercial |
$13,404.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,808.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,170.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,681.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,447.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,149.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,893.82
|
| Rate for Payer: Cash Price |
$4,468.20
|
| Rate for Payer: Cigna Commercial |
$13,702.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,334.68
|
| Rate for Payer: Health EOS Commercial |
$13,255.66
|
| Rate for Payer: HFN Commercial |
$13,702.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,170.50
|
| Rate for Payer: Multiplan Commercial |
$11,915.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,936.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,702.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,298.06
|
| Rate for Payer: Quartz Commercial |
$9,681.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8,936.40
|
| Rate for Payer: The Alliance Commercial |
$59,576.00
|
| Rate for Payer: WEA Trust Commercial |
$8,191.70
|
| Rate for Payer: WPS Commercial |
$11,031.99
|
|
|
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 |
$7,298.06 |
| Max. Negotiated Rate |
$13,702.48 |
| Rate for Payer: Aetna Commercial |
$13,404.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,808.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,893.82
|
| Rate for Payer: Cash Price |
$4,468.20
|
| Rate for Payer: Cigna Commercial |
$13,702.48
|
| Rate for Payer: Health EOS Commercial |
$13,255.66
|
| Rate for Payer: HFN Commercial |
$13,702.48
|
| Rate for Payer: Multiplan Commercial |
$11,915.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,936.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,702.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,298.06
|
| Rate for Payer: Quartz Commercial |
$8,936.40
|
| Rate for Payer: WEA Trust Commercial |
$8,191.70
|
| Rate for Payer: WPS Commercial |
$11,031.99
|
|
|
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 |
$7,881.65 |
| Max. Negotiated Rate |
$14,798.20 |
| Rate for Payer: Aetna Commercial |
$14,476.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,833.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,525.05
|
| Rate for Payer: Cash Price |
$4,825.50
|
| Rate for Payer: Cigna Commercial |
$14,798.20
|
| Rate for Payer: Health EOS Commercial |
$14,315.65
|
| Rate for Payer: HFN Commercial |
$14,798.20
|
| Rate for Payer: Multiplan Commercial |
$12,868.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,651.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,798.20
|
| Rate for Payer: Quartz Beloit One Network |
$7,881.65
|
| Rate for Payer: Quartz Commercial |
$9,651.00
|
| Rate for Payer: WEA Trust Commercial |
$8,846.75
|
| Rate for Payer: WPS Commercial |
$11,914.16
|
|
|
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 |
$4,503.80 |
| Max. Negotiated Rate |
$64,340.00 |
| Rate for Payer: Aetna Commercial |
$14,476.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,833.10
|
| Rate for Payer: Aetna Managed Medicare |
$4,503.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,455.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,042.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,720.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,525.05
|
| Rate for Payer: Cash Price |
$4,825.50
|
| Rate for Payer: Cigna Commercial |
$14,798.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,001.17
|
| Rate for Payer: Health EOS Commercial |
$14,315.65
|
| Rate for Payer: HFN Commercial |
$14,798.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,063.75
|
| Rate for Payer: Multiplan Commercial |
$12,868.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,651.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,798.20
|
| Rate for Payer: Quartz Beloit One Network |
$7,881.65
|
| Rate for Payer: Quartz Commercial |
$10,455.25
|
| Rate for Payer: Quartz Medicare Advantage |
$9,651.00
|
| Rate for Payer: The Alliance Commercial |
$64,340.00
|
| Rate for Payer: WEA Trust Commercial |
$8,846.75
|
| Rate for Payer: WPS Commercial |
$11,914.16
|
|
|
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 |
$10,336.06 |
| Max. Negotiated Rate |
$19,406.48 |
| Rate for Payer: Aetna Commercial |
$18,984.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,140.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,179.82
|
| Rate for Payer: Cash Price |
$6,328.20
|
| Rate for Payer: Cigna Commercial |
$19,406.48
|
| Rate for Payer: Health EOS Commercial |
$18,773.66
|
| Rate for Payer: HFN Commercial |
$19,406.48
|
| Rate for Payer: Multiplan Commercial |
$16,875.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,656.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,406.48
|
| Rate for Payer: Quartz Beloit One Network |
$10,336.06
|
| Rate for Payer: Quartz Commercial |
$12,656.40
|
| Rate for Payer: WEA Trust Commercial |
$11,601.70
|
| Rate for Payer: WPS Commercial |
$15,624.33
|
|
|
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 |
$5,906.32 |
| Max. Negotiated Rate |
$84,376.00 |
| Rate for Payer: Aetna Commercial |
$18,984.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,140.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,906.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,711.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,547.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,125.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,179.82
|
| Rate for Payer: Cash Price |
$6,328.20
|
| Rate for Payer: Cigna Commercial |
$19,406.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,804.20
|
| Rate for Payer: Health EOS Commercial |
$18,773.66
|
| Rate for Payer: HFN Commercial |
$19,406.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,820.50
|
| Rate for Payer: Multiplan Commercial |
$16,875.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,656.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,406.48
|
| Rate for Payer: Quartz Beloit One Network |
$10,336.06
|
| Rate for Payer: Quartz Commercial |
$13,711.10
|
| Rate for Payer: Quartz Medicare Advantage |
$12,656.40
|
| Rate for Payer: The Alliance Commercial |
$84,376.00
|
| Rate for Payer: WEA Trust Commercial |
$11,601.70
|
| Rate for Payer: WPS Commercial |
$15,624.33
|
|
|
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 |
$11,704.28 |
| Max. Negotiated Rate |
$167,204.00 |
| Rate for Payer: Aetna Commercial |
$37,620.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35,948.86
|
| Rate for Payer: Aetna Managed Medicare |
$11,704.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,170.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,900.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,064.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,154.53
|
| Rate for Payer: Cash Price |
$12,540.30
|
| Rate for Payer: Cigna Commercial |
$38,456.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,391.84
|
| Rate for Payer: Health EOS Commercial |
$37,202.89
|
| Rate for Payer: HFN Commercial |
$38,456.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,350.75
|
| Rate for Payer: Multiplan Commercial |
$33,440.80
|
| Rate for Payer: NAPHCARE Commercial |
$25,080.60
|
| Rate for Payer: Preferred Network Access Commercial |
$38,456.92
|
| Rate for Payer: Quartz Beloit One Network |
$20,482.49
|
| Rate for Payer: Quartz Commercial |
$27,170.65
|
| Rate for Payer: Quartz Medicare Advantage |
$25,080.60
|
| Rate for Payer: The Alliance Commercial |
$167,204.00
|
| Rate for Payer: WEA Trust Commercial |
$22,990.55
|
| Rate for Payer: WPS Commercial |
$30,962.00
|
|
|
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 |
$20,482.49 |
| Max. Negotiated Rate |
$38,456.92 |
| Rate for Payer: Aetna Commercial |
$37,620.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35,948.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,154.53
|
| Rate for Payer: Cash Price |
$12,540.30
|
| Rate for Payer: Cigna Commercial |
$38,456.92
|
| Rate for Payer: Health EOS Commercial |
$37,202.89
|
| Rate for Payer: HFN Commercial |
$38,456.92
|
| Rate for Payer: Multiplan Commercial |
$33,440.80
|
| Rate for Payer: NAPHCARE Commercial |
$25,080.60
|
| Rate for Payer: Preferred Network Access Commercial |
$38,456.92
|
| Rate for Payer: Quartz Beloit One Network |
$20,482.49
|
| Rate for Payer: Quartz Commercial |
$25,080.60
|
| Rate for Payer: WEA Trust Commercial |
$22,990.55
|
| Rate for Payer: WPS Commercial |
$30,962.00
|
|
|
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 |
$5,955.88 |
| Max. Negotiated Rate |
$85,084.00 |
| Rate for Payer: Aetna Commercial |
$19,143.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,293.06
|
| Rate for Payer: Aetna Managed Medicare |
$5,955.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,826.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,635.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,210.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,273.63
|
| Rate for Payer: Cash Price |
$6,381.30
|
| Rate for Payer: Cigna Commercial |
$19,569.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,903.25
|
| Rate for Payer: Health EOS Commercial |
$18,931.19
|
| Rate for Payer: HFN Commercial |
$19,569.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,953.25
|
| Rate for Payer: Multiplan Commercial |
$17,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,762.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,569.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,422.79
|
| Rate for Payer: Quartz Commercial |
$13,826.15
|
| Rate for Payer: Quartz Medicare Advantage |
$12,762.60
|
| Rate for Payer: The Alliance Commercial |
$85,084.00
|
| Rate for Payer: WEA Trust Commercial |
$11,699.05
|
| Rate for Payer: WPS Commercial |
$15,755.43
|
|
|
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 |
$10,422.79 |
| Max. Negotiated Rate |
$19,569.32 |
| Rate for Payer: Aetna Commercial |
$19,143.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,293.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,273.63
|
| Rate for Payer: Cash Price |
$6,381.30
|
| Rate for Payer: Cigna Commercial |
$19,569.32
|
| Rate for Payer: Health EOS Commercial |
$18,931.19
|
| Rate for Payer: HFN Commercial |
$19,569.32
|
| Rate for Payer: Multiplan Commercial |
$17,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,762.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19,569.32
|
| Rate for Payer: Quartz Beloit One Network |
$10,422.79
|
| Rate for Payer: Quartz Commercial |
$12,762.60
|
| Rate for Payer: WEA Trust Commercial |
$11,699.05
|
| Rate for Payer: WPS Commercial |
$15,755.43
|
|
|
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 |
$6,587.84 |
| Max. Negotiated Rate |
$94,112.00 |
| Rate for Payer: Aetna Commercial |
$21,175.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,234.08
|
| Rate for Payer: Aetna Managed Medicare |
$6,587.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,293.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,764.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,293.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,469.84
|
| Rate for Payer: Cash Price |
$7,058.40
|
| Rate for Payer: Cigna Commercial |
$21,645.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,166.27
|
| Rate for Payer: Health EOS Commercial |
$20,939.92
|
| Rate for Payer: HFN Commercial |
$21,645.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,646.00
|
| Rate for Payer: Multiplan Commercial |
$18,822.40
|
| Rate for Payer: NAPHCARE Commercial |
$14,116.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21,645.76
|
| Rate for Payer: Quartz Beloit One Network |
$11,528.72
|
| Rate for Payer: Quartz Commercial |
$15,293.20
|
| Rate for Payer: Quartz Medicare Advantage |
$14,116.80
|
| Rate for Payer: The Alliance Commercial |
$94,112.00
|
| Rate for Payer: WEA Trust Commercial |
$12,940.40
|
| Rate for Payer: WPS Commercial |
$17,427.19
|
|
|
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 |
$11,528.72 |
| Max. Negotiated Rate |
$21,645.76 |
| Rate for Payer: Aetna Commercial |
$21,175.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,234.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,469.84
|
| Rate for Payer: Cash Price |
$7,058.40
|
| Rate for Payer: Cigna Commercial |
$21,645.76
|
| Rate for Payer: Health EOS Commercial |
$20,939.92
|
| Rate for Payer: HFN Commercial |
$21,645.76
|
| Rate for Payer: Multiplan Commercial |
$18,822.40
|
| Rate for Payer: NAPHCARE Commercial |
$14,116.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21,645.76
|
| Rate for Payer: Quartz Beloit One Network |
$11,528.72
|
| Rate for Payer: Quartz Commercial |
$14,116.80
|
| Rate for Payer: WEA Trust Commercial |
$12,940.40
|
| Rate for Payer: WPS Commercial |
$17,427.19
|
|
