|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 53MM 6942-5-053
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4175626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 53MM 6942-5-053
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4175626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 55MM 6942-5-055
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 55MM 6942-5-055
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 56MM 6942-5-056
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 56MM 6942-5-056
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 57MM 6942-5-057
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4519607
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 57MM 6942-5-057
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4519607
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 58MM 6942-5-058
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 58MM 6942-5-058
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 59MM 6942-5-059
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4519606
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 59MM 6942-5-059
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4519606
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 60MM 6942-5-060
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4519605
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 60MM 6942-5-060
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4519605
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 61MM 6942-5-061
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,390.22 |
| Max. Negotiated Rate |
$4,487.76 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$2,926.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 61MM 6942-5-061
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.84 |
| Max. Negotiated Rate |
$19,512.00 |
| Rate for Payer: Aetna Commercial |
$4,390.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,195.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,439.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.34
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.73
|
| Rate for Payer: Health EOS Commercial |
$4,341.42
|
| Rate for Payer: HFN Commercial |
$4,487.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.50
|
| Rate for Payer: Multiplan Commercial |
$3,902.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.22
|
| Rate for Payer: Quartz Commercial |
$3,170.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.80
|
| Rate for Payer: The Alliance Commercial |
$19,512.00
|
| Rate for Payer: WEA Trust Commercial |
$2,682.90
|
| Rate for Payer: WPS Commercial |
$3,613.13
|
|
|
HEADGEAR INFANT LARGE 777040L
|
Facility
|
IP
|
$159.00
|
|
| Hospital Charge Code |
2974777
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.91 |
| Max. Negotiated Rate |
$146.28 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$95.40
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
HEADGEAR INFANT LARGE 777040L
|
Facility
|
OP
|
$159.00
|
|
| Hospital Charge Code |
2974777
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$103.35
|
| Rate for Payer: Quartz Medicare Advantage |
$95.40
|
| Rate for Payer: The Alliance Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
HEADGEAR INFANT MED 777040ML
|
Facility
|
IP
|
$159.00
|
|
| Hospital Charge Code |
2974778
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.91 |
| Max. Negotiated Rate |
$146.28 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$95.40
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
HEADGEAR INFANT MED 777040ML
|
Facility
|
OP
|
$159.00
|
|
| Hospital Charge Code |
2974778
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$103.35
|
| Rate for Payer: Quartz Medicare Advantage |
$95.40
|
| Rate for Payer: The Alliance Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
HEAD MODULAR HUMERAL
|
Facility
|
OP
|
$9,561.00
|
|
| Hospital Charge Code |
2967490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,677.08 |
| Max. Negotiated Rate |
$38,244.00 |
| Rate for Payer: Aetna Commercial |
$8,604.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,222.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,677.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,214.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,780.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,589.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,067.33
|
| Rate for Payer: Cash Price |
$2,868.30
|
| Rate for Payer: Cigna Commercial |
$8,796.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,350.34
|
| Rate for Payer: Health EOS Commercial |
$8,509.29
|
| Rate for Payer: HFN Commercial |
$8,796.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,170.75
|
| Rate for Payer: Multiplan Commercial |
$7,648.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,736.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,796.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,684.89
|
| Rate for Payer: Quartz Commercial |
$6,214.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,736.60
|
| Rate for Payer: The Alliance Commercial |
$38,244.00
|
| Rate for Payer: WEA Trust Commercial |
$5,258.55
|
| Rate for Payer: WPS Commercial |
$7,081.83
|
|
|
HEAD MODULAR HUMERAL
|
Facility
|
IP
|
$9,561.00
|
|
| Hospital Charge Code |
2967490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,684.89 |
| Max. Negotiated Rate |
$8,796.12 |
| Rate for Payer: Aetna Commercial |
$8,604.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,222.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,067.33
|
| Rate for Payer: Cash Price |
$2,868.30
|
| Rate for Payer: Cigna Commercial |
$8,796.12
|
| Rate for Payer: Health EOS Commercial |
$8,509.29
|
| Rate for Payer: HFN Commercial |
$8,796.12
|
| Rate for Payer: Multiplan Commercial |
$7,648.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,736.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,796.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,684.89
|
| Rate for Payer: Quartz Commercial |
$5,736.60
|
| Rate for Payer: WEA Trust Commercial |
$5,258.55
|
| Rate for Payer: WPS Commercial |
$7,081.83
|
|
|
HEAD & NECK TUMOR RESECTION/RECONSTRUCTION
|
Facility
|
OP
|
$4,048.00
|
|
| Hospital Charge Code |
2950500
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,133.44 |
| Max. Negotiated Rate |
$16,192.00 |
| Rate for Payer: Aetna Commercial |
$3,643.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,481.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,133.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,631.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,024.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,943.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,145.44
|
| Rate for Payer: Cash Price |
$1,214.40
|
| Rate for Payer: Cigna Commercial |
$3,724.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,265.26
|
| Rate for Payer: Health EOS Commercial |
$3,602.72
|
| Rate for Payer: HFN Commercial |
$3,724.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,036.00
|
| Rate for Payer: Multiplan Commercial |
$3,238.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,428.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,724.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,983.52
|
| Rate for Payer: Quartz Commercial |
$2,631.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,428.80
|
| Rate for Payer: The Alliance Commercial |
$16,192.00
|
| Rate for Payer: WEA Trust Commercial |
$2,226.40
|
| Rate for Payer: WPS Commercial |
$2,998.35
|
|
|
HEAD & NECK TUMOR RESECTION/RECONSTRUCTION
|
Facility
|
IP
|
$4,048.00
|
|
| Hospital Charge Code |
2950500
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,983.52 |
| Max. Negotiated Rate |
$3,724.16 |
| Rate for Payer: Aetna Commercial |
$3,643.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,481.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,145.44
|
| Rate for Payer: Cash Price |
$1,214.40
|
| Rate for Payer: Cigna Commercial |
$3,724.16
|
| Rate for Payer: Health EOS Commercial |
$3,602.72
|
| Rate for Payer: HFN Commercial |
$3,724.16
|
| Rate for Payer: Multiplan Commercial |
$3,238.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,428.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,724.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,983.52
|
| Rate for Payer: Quartz Commercial |
$2,428.80
|
| Rate for Payer: WEA Trust Commercial |
$2,226.40
|
| Rate for Payer: WPS Commercial |
$2,998.35
|
|
|
HEAD RESTRAINT ALLEN UNIVERSAL A-90023
|
Facility
|
IP
|
$447.00
|
|
| Hospital Charge Code |
5106864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$219.03 |
| Max. Negotiated Rate |
$411.24 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$268.20
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
