|
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 |
$12,301.45 |
| Max. Negotiated Rate |
$23,096.60 |
| Rate for Payer: Aetna Commercial |
$22,594.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,590.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,305.65
|
| Rate for Payer: Cash Price |
$7,531.50
|
| Rate for Payer: Cigna Commercial |
$23,096.60
|
| Rate for Payer: Health EOS Commercial |
$22,343.45
|
| Rate for Payer: HFN Commercial |
$23,096.60
|
| Rate for Payer: Multiplan Commercial |
$20,084.00
|
| Rate for Payer: NAPHCARE Commercial |
$15,063.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23,096.60
|
| Rate for Payer: Quartz Beloit One Network |
$12,301.45
|
| Rate for Payer: Quartz Commercial |
$15,063.00
|
| Rate for Payer: WEA Trust Commercial |
$13,807.75
|
| Rate for Payer: WPS Commercial |
$18,595.27
|
|
|
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 |
$7,029.40 |
| Max. Negotiated Rate |
$100,420.00 |
| Rate for Payer: Aetna Commercial |
$22,594.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,590.30
|
| Rate for Payer: Aetna Managed Medicare |
$7,029.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,318.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,552.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,050.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,305.65
|
| Rate for Payer: Cash Price |
$7,531.50
|
| Rate for Payer: Cigna Commercial |
$23,096.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,048.76
|
| Rate for Payer: Health EOS Commercial |
$22,343.45
|
| Rate for Payer: HFN Commercial |
$23,096.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,828.75
|
| Rate for Payer: Multiplan Commercial |
$20,084.00
|
| Rate for Payer: NAPHCARE Commercial |
$15,063.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23,096.60
|
| Rate for Payer: Quartz Beloit One Network |
$12,301.45
|
| Rate for Payer: Quartz Commercial |
$16,318.25
|
| Rate for Payer: Quartz Medicare Advantage |
$15,063.00
|
| Rate for Payer: The Alliance Commercial |
$100,420.00
|
| Rate for Payer: WEA Trust Commercial |
$13,807.75
|
| Rate for Payer: WPS Commercial |
$18,595.27
|
|
|
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 |
$11,920.72 |
| Max. Negotiated Rate |
$22,381.76 |
| Rate for Payer: Aetna Commercial |
$21,895.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,922.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,893.84
|
| Rate for Payer: Cash Price |
$7,298.40
|
| Rate for Payer: Cigna Commercial |
$22,381.76
|
| Rate for Payer: Health EOS Commercial |
$21,651.92
|
| Rate for Payer: HFN Commercial |
$22,381.76
|
| Rate for Payer: Multiplan Commercial |
$19,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$14,596.80
|
| Rate for Payer: Preferred Network Access Commercial |
$22,381.76
|
| Rate for Payer: Quartz Beloit One Network |
$11,920.72
|
| Rate for Payer: Quartz Commercial |
$14,596.80
|
| Rate for Payer: WEA Trust Commercial |
$13,380.40
|
| Rate for Payer: WPS Commercial |
$18,019.75
|
|
|
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 |
$6,811.84 |
| Max. Negotiated Rate |
$97,312.00 |
| Rate for Payer: Aetna Commercial |
$21,895.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,922.08
|
| Rate for Payer: Aetna Managed Medicare |
$6,811.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,813.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,164.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,677.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,893.84
|
| Rate for Payer: Cash Price |
$7,298.40
|
| Rate for Payer: Cigna Commercial |
$22,381.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,613.95
|
| Rate for Payer: Health EOS Commercial |
$21,651.92
|
| Rate for Payer: HFN Commercial |
$22,381.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,246.00
|
| Rate for Payer: Multiplan Commercial |
$19,462.40
|
| Rate for Payer: NAPHCARE Commercial |
$14,596.80
|
| Rate for Payer: Preferred Network Access Commercial |
$22,381.76
|
| Rate for Payer: Quartz Beloit One Network |
$11,920.72
|
| Rate for Payer: Quartz Commercial |
$15,813.20
|
| Rate for Payer: Quartz Medicare Advantage |
$14,596.80
|
| Rate for Payer: The Alliance Commercial |
$97,312.00
|
| Rate for Payer: WEA Trust Commercial |
$13,380.40
|
| Rate for Payer: WPS Commercial |
$18,019.75
|
|
|
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 |
$21,190.54 |
| Max. Negotiated Rate |
$39,786.32 |
| Rate for Payer: Aetna Commercial |
$38,921.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37,191.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,920.38
|
| Rate for Payer: Cash Price |
$12,973.80
|
| Rate for Payer: Cigna Commercial |
$39,786.32
|
| Rate for Payer: Health EOS Commercial |
$38,488.94
|
| Rate for Payer: HFN Commercial |
$39,786.32
|
| Rate for Payer: Multiplan Commercial |
$34,596.80
|
| Rate for Payer: NAPHCARE Commercial |
$25,947.60
|
| Rate for Payer: Preferred Network Access Commercial |
$39,786.32
|
| Rate for Payer: Quartz Beloit One Network |
$21,190.54
|
| Rate for Payer: Quartz Commercial |
$25,947.60
|
| Rate for Payer: WEA Trust Commercial |
$23,785.30
|
| Rate for Payer: WPS Commercial |
$32,032.31
|
|
|
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 |
$12,108.88 |
| Max. Negotiated Rate |
$172,984.00 |
| Rate for Payer: Aetna Commercial |
$38,921.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37,191.56
|
| Rate for Payer: Aetna Managed Medicare |
$12,108.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,109.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,623.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,758.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,920.38
|
| Rate for Payer: Cash Price |
$12,973.80
|
| Rate for Payer: Cigna Commercial |
$39,786.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,200.46
|
| Rate for Payer: Health EOS Commercial |
$38,488.94
|
| Rate for Payer: HFN Commercial |
$39,786.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,434.50
|
| Rate for Payer: Multiplan Commercial |
$34,596.80
|
| Rate for Payer: NAPHCARE Commercial |
$25,947.60
|
| Rate for Payer: Preferred Network Access Commercial |
$39,786.32
|
| Rate for Payer: Quartz Beloit One Network |
$21,190.54
|
| Rate for Payer: Quartz Commercial |
$28,109.90
|
| Rate for Payer: Quartz Medicare Advantage |
$25,947.60
|
| Rate for Payer: The Alliance Commercial |
$172,984.00
|
| Rate for Payer: WEA Trust Commercial |
$23,785.30
|
| Rate for Payer: WPS Commercial |
$32,032.31
|
|
|
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 |
$22,831.55 |
| Max. Negotiated Rate |
$42,867.40 |
| Rate for Payer: Aetna Commercial |
$41,935.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40,071.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24,695.35
|
| Rate for Payer: Cash Price |
$13,978.50
|
| Rate for Payer: Cigna Commercial |
$42,867.40
|
| Rate for Payer: Health EOS Commercial |
$41,469.55
|
| Rate for Payer: HFN Commercial |
$42,867.40
|
| Rate for Payer: Multiplan Commercial |
$37,276.00
|
| Rate for Payer: NAPHCARE Commercial |
$27,957.00
|
| Rate for Payer: Preferred Network Access Commercial |
$42,867.40
|
| Rate for Payer: Quartz Beloit One Network |
$22,831.55
|
| Rate for Payer: Quartz Commercial |
$27,957.00
|
| Rate for Payer: WEA Trust Commercial |
$25,627.25
|
| Rate for Payer: WPS Commercial |
$34,512.92
|
|
|
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 |
$13,046.60 |
| Max. Negotiated Rate |
$186,380.00 |
| Rate for Payer: Aetna Commercial |
$41,935.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40,071.70
|
| Rate for Payer: Aetna Managed Medicare |
$13,046.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,286.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,297.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,365.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24,695.35
|
| Rate for Payer: Cash Price |
$13,978.50
|
| Rate for Payer: Cigna Commercial |
$42,867.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,074.56
|
| Rate for Payer: Health EOS Commercial |
$41,469.55
|
| Rate for Payer: HFN Commercial |
$42,867.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,946.25
|
| Rate for Payer: Multiplan Commercial |
$37,276.00
|
| Rate for Payer: NAPHCARE Commercial |
$27,957.00
|
| Rate for Payer: Preferred Network Access Commercial |
$42,867.40
|
| Rate for Payer: Quartz Beloit One Network |
$22,831.55
|
| Rate for Payer: Quartz Commercial |
$30,286.75
|
| Rate for Payer: Quartz Medicare Advantage |
$27,957.00
|
| Rate for Payer: The Alliance Commercial |
$186,380.00
|
| Rate for Payer: WEA Trust Commercial |
$25,627.25
|
| Rate for Payer: WPS Commercial |
$34,512.92
|
|
|
FEMORAL TROCHLEA 20mm OFFSET
|
Facility
|
IP
|
$24,667.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2964729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,086.83 |
| Max. Negotiated Rate |
$22,693.64 |
| Rate for Payer: Aetna Commercial |
$22,200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,213.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,073.51
|
| Rate for Payer: Cash Price |
$7,400.10
|
| Rate for Payer: Cigna Commercial |
$22,693.64
|
| Rate for Payer: Health EOS Commercial |
$21,953.63
|
| Rate for Payer: HFN Commercial |
$22,693.64
|
| Rate for Payer: Multiplan Commercial |
$19,733.60
|
| Rate for Payer: NAPHCARE Commercial |
$14,800.20
|
| Rate for Payer: Preferred Network Access Commercial |
$22,693.64
|
| Rate for Payer: Quartz Beloit One Network |
$12,086.83
|
| Rate for Payer: Quartz Commercial |
$14,800.20
|
| Rate for Payer: WEA Trust Commercial |
$13,566.85
|
| Rate for Payer: WPS Commercial |
$18,270.85
|
|
|
FEMORAL TROCHLEA 20mm OFFSET
|
Facility
|
OP
|
$24,667.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2964729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,906.76 |
| Max. Negotiated Rate |
$98,668.00 |
| Rate for Payer: Aetna Commercial |
$22,200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,213.62
|
| Rate for Payer: Aetna Managed Medicare |
$6,906.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,033.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,333.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,840.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,073.51
|
| Rate for Payer: Cash Price |
$7,400.10
|
| Rate for Payer: Cigna Commercial |
$22,693.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,803.65
|
| Rate for Payer: Health EOS Commercial |
$21,953.63
|
| Rate for Payer: HFN Commercial |
$22,693.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,500.25
|
| Rate for Payer: Multiplan Commercial |
$19,733.60
|
| Rate for Payer: NAPHCARE Commercial |
$14,800.20
|
| Rate for Payer: Preferred Network Access Commercial |
$22,693.64
|
| Rate for Payer: Quartz Beloit One Network |
$12,086.83
|
| Rate for Payer: Quartz Commercial |
$16,033.55
|
| Rate for Payer: Quartz Medicare Advantage |
$14,800.20
|
| Rate for Payer: The Alliance Commercial |
$98,668.00
|
| Rate for Payer: WEA Trust Commercial |
$13,566.85
|
| Rate for Payer: WPS Commercial |
$18,270.85
|
|
|
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 |
$297.08 |
| Max. Negotiated Rate |
$4,244.00 |
| Rate for Payer: Aetna Commercial |
$954.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$912.46
|
| Rate for Payer: Aetna Managed Medicare |
$297.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$689.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$530.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$509.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$562.33
|
| Rate for Payer: Cash Price |
$318.30
|
| Rate for Payer: Cigna Commercial |
$976.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$593.74
|
| Rate for Payer: Health EOS Commercial |
$944.29
|
| Rate for Payer: HFN Commercial |
$976.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$795.75
|
| Rate for Payer: Multiplan Commercial |
$848.80
|
| Rate for Payer: NAPHCARE Commercial |
$636.60
|
| Rate for Payer: Preferred Network Access Commercial |
$976.12
|
| Rate for Payer: Quartz Beloit One Network |
$519.89
|
| Rate for Payer: Quartz Commercial |
$689.65
|
| Rate for Payer: Quartz Medicare Advantage |
$636.60
|
| Rate for Payer: The Alliance Commercial |
$4,244.00
|
| Rate for Payer: WEA Trust Commercial |
$583.55
|
| Rate for Payer: WPS Commercial |
$785.88
|
|
|
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 |
$519.89 |
| Max. Negotiated Rate |
$976.12 |
| Rate for Payer: Aetna Commercial |
$954.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$912.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$562.33
|
| Rate for Payer: Cash Price |
$318.30
|
| Rate for Payer: Cigna Commercial |
$976.12
|
| Rate for Payer: Health EOS Commercial |
$944.29
|
| Rate for Payer: HFN Commercial |
$976.12
|
| Rate for Payer: Multiplan Commercial |
$848.80
|
| Rate for Payer: NAPHCARE Commercial |
$636.60
|
| Rate for Payer: Preferred Network Access Commercial |
$976.12
|
| Rate for Payer: Quartz Beloit One Network |
$519.89
|
| Rate for Payer: Quartz Commercial |
$636.60
|
| Rate for Payer: WEA Trust Commercial |
$583.55
|
| Rate for Payer: WPS Commercial |
$785.88
|
|
|
FEMUR BONE GRAFTING
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2959858
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FEMUR BONE GRAFTING
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2959858
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FEMUR, EPIPHYSIODESIS
|
Facility
|
IP
|
$5,314.00
|
|
| Hospital Charge Code |
2960015
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,603.86 |
| Max. Negotiated Rate |
$4,888.88 |
| Rate for Payer: Aetna Commercial |
$4,782.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,570.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,816.42
|
| Rate for Payer: Cash Price |
$1,594.20
|
| Rate for Payer: Cigna Commercial |
$4,888.88
|
| Rate for Payer: Health EOS Commercial |
$4,729.46
|
| Rate for Payer: HFN Commercial |
$4,888.88
|
| Rate for Payer: Multiplan Commercial |
$4,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,188.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,888.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,603.86
|
| Rate for Payer: Quartz Commercial |
$3,188.40
|
| Rate for Payer: WEA Trust Commercial |
$2,922.70
|
| Rate for Payer: WPS Commercial |
$3,936.08
|
|
|
FEMUR, EPIPHYSIODESIS
|
Facility
|
OP
|
$5,314.00
|
|
| Hospital Charge Code |
2960015
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,487.92 |
| Max. Negotiated Rate |
$21,256.00 |
| Rate for Payer: Aetna Commercial |
$4,782.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,570.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,487.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,454.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,657.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,550.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,816.42
|
| Rate for Payer: Cash Price |
$1,594.20
|
| Rate for Payer: Cigna Commercial |
$4,888.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,973.71
|
| Rate for Payer: Health EOS Commercial |
$4,729.46
|
| Rate for Payer: HFN Commercial |
$4,888.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,985.50
|
| Rate for Payer: Multiplan Commercial |
$4,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,188.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,888.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,603.86
|
| Rate for Payer: Quartz Commercial |
$3,454.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,188.40
|
| Rate for Payer: The Alliance Commercial |
$21,256.00
|
| Rate for Payer: WEA Trust Commercial |
$2,922.70
|
| Rate for Payer: WPS Commercial |
$3,936.08
|
|
|
FEMUR LPS-FLEX TIVANIUM SZ F LT 00-5968-016-51
|
Facility
|
IP
|
$21,849.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967471
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,706.01 |
| Max. Negotiated Rate |
$20,101.08 |
| Rate for Payer: Aetna Commercial |
$19,664.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,790.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,579.97
|
| Rate for Payer: Cash Price |
$6,554.70
|
| Rate for Payer: Cigna Commercial |
$20,101.08
|
| Rate for Payer: Health EOS Commercial |
$19,445.61
|
| Rate for Payer: HFN Commercial |
$20,101.08
|
| Rate for Payer: Multiplan Commercial |
$17,479.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,109.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,101.08
|
| Rate for Payer: Quartz Beloit One Network |
$10,706.01
|
| Rate for Payer: Quartz Commercial |
$13,109.40
|
| Rate for Payer: WEA Trust Commercial |
$12,016.95
|
| Rate for Payer: WPS Commercial |
$16,183.55
|
|
|
FEMUR LPS-FLEX TIVANIUM SZ F LT 00-5968-016-51
|
Facility
|
OP
|
$21,849.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967471
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,117.72 |
| Max. Negotiated Rate |
$87,396.00 |
| Rate for Payer: Aetna Commercial |
$19,664.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,790.14
|
| Rate for Payer: Aetna Managed Medicare |
$6,117.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,201.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,924.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,487.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,579.97
|
| Rate for Payer: Cash Price |
$6,554.70
|
| Rate for Payer: Cigna Commercial |
$20,101.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,226.70
|
| Rate for Payer: Health EOS Commercial |
$19,445.61
|
| Rate for Payer: HFN Commercial |
$20,101.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,386.75
|
| Rate for Payer: Multiplan Commercial |
$17,479.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,109.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,101.08
|
| Rate for Payer: Quartz Beloit One Network |
$10,706.01
|
| Rate for Payer: Quartz Commercial |
$14,201.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13,109.40
|
| Rate for Payer: The Alliance Commercial |
$87,396.00
|
| Rate for Payer: WEA Trust Commercial |
$12,016.95
|
| Rate for Payer: WPS Commercial |
$16,183.55
|
|
|
FEMUR NEXGEN POROUS CR-FLEX SZ E-LT 00-5952-015-01
|
Facility
|
OP
|
$14,382.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,026.96 |
| Max. Negotiated Rate |
$57,528.00 |
| Rate for Payer: Aetna Commercial |
$12,943.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,368.52
|
| Rate for Payer: Aetna Managed Medicare |
$4,026.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,348.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,191.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,622.46
|
| Rate for Payer: Cash Price |
$4,314.60
|
| Rate for Payer: Cigna Commercial |
$13,231.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,048.17
|
| Rate for Payer: Health EOS Commercial |
$12,799.98
|
| Rate for Payer: HFN Commercial |
$13,231.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,786.50
|
| Rate for Payer: Multiplan Commercial |
$11,505.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,629.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,231.44
|
| Rate for Payer: Quartz Beloit One Network |
$7,047.18
|
| Rate for Payer: Quartz Commercial |
$9,348.30
|
| Rate for Payer: Quartz Medicare Advantage |
$8,629.20
|
| Rate for Payer: The Alliance Commercial |
$57,528.00
|
| Rate for Payer: WEA Trust Commercial |
$7,910.10
|
| Rate for Payer: WPS Commercial |
$10,652.75
|
|
|
FEMUR NEXGEN POROUS CR-FLEX SZ E-LT 00-5952-015-01
|
Facility
|
IP
|
$14,382.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,047.18 |
| Max. Negotiated Rate |
$13,231.44 |
| Rate for Payer: Aetna Commercial |
$12,943.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,368.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,622.46
|
| Rate for Payer: Cash Price |
$4,314.60
|
| Rate for Payer: Cigna Commercial |
$13,231.44
|
| Rate for Payer: Health EOS Commercial |
$12,799.98
|
| Rate for Payer: HFN Commercial |
$13,231.44
|
| Rate for Payer: Multiplan Commercial |
$11,505.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,629.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,231.44
|
| Rate for Payer: Quartz Beloit One Network |
$7,047.18
|
| Rate for Payer: Quartz Commercial |
$8,629.20
|
| Rate for Payer: WEA Trust Commercial |
$7,910.10
|
| Rate for Payer: WPS Commercial |
$10,652.75
|
|
|
FEMUR NEXGEN POROUS CR-FLEX SZ G-LT 00-5952-017-01
|
Facility
|
IP
|
$14,382.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456754
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,047.18 |
| Max. Negotiated Rate |
$13,231.44 |
| Rate for Payer: Aetna Commercial |
$12,943.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,368.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,622.46
|
| Rate for Payer: Cash Price |
$4,314.60
|
| Rate for Payer: Cigna Commercial |
$13,231.44
|
| Rate for Payer: Health EOS Commercial |
$12,799.98
|
| Rate for Payer: HFN Commercial |
$13,231.44
|
| Rate for Payer: Multiplan Commercial |
$11,505.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,629.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,231.44
|
| Rate for Payer: Quartz Beloit One Network |
$7,047.18
|
| Rate for Payer: Quartz Commercial |
$8,629.20
|
| Rate for Payer: WEA Trust Commercial |
$7,910.10
|
| Rate for Payer: WPS Commercial |
$10,652.75
|
|
|
FEMUR NEXGEN POROUS CR-FLEX SZ G-LT 00-5952-017-01
|
Facility
|
OP
|
$14,382.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456754
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,026.96 |
| Max. Negotiated Rate |
$57,528.00 |
| Rate for Payer: Aetna Commercial |
$12,943.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,368.52
|
| Rate for Payer: Aetna Managed Medicare |
$4,026.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,348.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,191.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,622.46
|
| Rate for Payer: Cash Price |
$4,314.60
|
| Rate for Payer: Cigna Commercial |
$13,231.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,048.17
|
| Rate for Payer: Health EOS Commercial |
$12,799.98
|
| Rate for Payer: HFN Commercial |
$13,231.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,786.50
|
| Rate for Payer: Multiplan Commercial |
$11,505.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,629.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,231.44
|
| Rate for Payer: Quartz Beloit One Network |
$7,047.18
|
| Rate for Payer: Quartz Commercial |
$9,348.30
|
| Rate for Payer: Quartz Medicare Advantage |
$8,629.20
|
| Rate for Payer: The Alliance Commercial |
$57,528.00
|
| Rate for Payer: WEA Trust Commercial |
$7,910.10
|
| Rate for Payer: WPS Commercial |
$10,652.75
|
|
|
FEMUR NEXGEN TIVANIUM LPS-FLEX SZ E RT 00-5968-015-52
|
Facility
|
OP
|
$14,382.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4242992
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,026.96 |
| Max. Negotiated Rate |
$57,528.00 |
| Rate for Payer: Aetna Commercial |
$12,943.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,368.52
|
| Rate for Payer: Aetna Managed Medicare |
$4,026.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,348.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,191.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,622.46
|
| Rate for Payer: Cash Price |
$4,314.60
|
| Rate for Payer: Cigna Commercial |
$13,231.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,048.17
|
| Rate for Payer: Health EOS Commercial |
$12,799.98
|
| Rate for Payer: HFN Commercial |
$13,231.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,786.50
|
| Rate for Payer: Multiplan Commercial |
$11,505.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,629.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,231.44
|
| Rate for Payer: Quartz Beloit One Network |
$7,047.18
|
| Rate for Payer: Quartz Commercial |
$9,348.30
|
| Rate for Payer: Quartz Medicare Advantage |
$8,629.20
|
| Rate for Payer: The Alliance Commercial |
$57,528.00
|
| Rate for Payer: WEA Trust Commercial |
$7,910.10
|
| Rate for Payer: WPS Commercial |
$10,652.75
|
|
|
FEMUR NEXGEN TIVANIUM LPS-FLEX SZ E RT 00-5968-015-52
|
Facility
|
IP
|
$14,382.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4242992
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,047.18 |
| Max. Negotiated Rate |
$13,231.44 |
| Rate for Payer: Aetna Commercial |
$12,943.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,368.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,622.46
|
| Rate for Payer: Cash Price |
$4,314.60
|
| Rate for Payer: Cigna Commercial |
$13,231.44
|
| Rate for Payer: Health EOS Commercial |
$12,799.98
|
| Rate for Payer: HFN Commercial |
$13,231.44
|
| Rate for Payer: Multiplan Commercial |
$11,505.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,629.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,231.44
|
| Rate for Payer: Quartz Beloit One Network |
$7,047.18
|
| Rate for Payer: Quartz Commercial |
$8,629.20
|
| Rate for Payer: WEA Trust Commercial |
$7,910.10
|
| Rate for Payer: WPS Commercial |
$10,652.75
|
|
|
FEMUR OXFORD TWIN PEG LARGE CEMENTED 161470
|
Facility
|
IP
|
$9,930.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,865.70 |
| Max. Negotiated Rate |
$9,135.60 |
| Rate for Payer: Aetna Commercial |
$8,937.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,539.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,262.90
|
| Rate for Payer: Cash Price |
$2,979.00
|
| Rate for Payer: Cigna Commercial |
$9,135.60
|
| Rate for Payer: Health EOS Commercial |
$8,837.70
|
| Rate for Payer: HFN Commercial |
$9,135.60
|
| Rate for Payer: Multiplan Commercial |
$7,944.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,958.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,135.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,865.70
|
| Rate for Payer: Quartz Commercial |
$5,958.00
|
| Rate for Payer: WEA Trust Commercial |
$5,461.50
|
| Rate for Payer: WPS Commercial |
$7,355.15
|
|
