|
HIP PROSTHESIS AUSTIN-MOORE 51MM 4021-08-51
|
Facility
|
IP
|
$6,107.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,112.13 |
| Max. Negotiated Rate |
$5,843.18 |
| Rate for Payer: Aetna Commercial |
$5,716.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,462.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,366.18
|
| Rate for Payer: Cash Price |
$1,832.10
|
| Rate for Payer: Cigna Commercial |
$5,843.18
|
| Rate for Payer: Health EOS Commercial |
$5,652.64
|
| Rate for Payer: HFN Commercial |
$5,843.18
|
| Rate for Payer: Multiplan Commercial |
$5,081.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,843.18
|
| Rate for Payer: Quartz Beloit One Network |
$3,112.13
|
| Rate for Payer: Quartz Commercial |
$3,810.77
|
| Rate for Payer: WEA Trust Commercial |
$3,493.20
|
| Rate for Payer: WPS Commercial |
$4,704.22
|
|
|
HIP PROSTHESIS AUSTIN-MOORE 51MM 4021-08-51
|
Facility
|
OP
|
$6,107.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,778.36 |
| Max. Negotiated Rate |
$5,843.18 |
| Rate for Payer: Aetna Commercial |
$5,716.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,462.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,778.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,128.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,175.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,048.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,366.18
|
| Rate for Payer: Cash Price |
$1,832.10
|
| Rate for Payer: Cigna Commercial |
$5,843.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,554.27
|
| Rate for Payer: Health EOS Commercial |
$5,652.64
|
| Rate for Payer: HFN Commercial |
$5,843.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,763.46
|
| Rate for Payer: Multiplan Commercial |
$5,081.02
|
| Rate for Payer: NAPHCARE Commercial |
$3,810.77
|
| Rate for Payer: Preferred Network Access Commercial |
$5,843.18
|
| Rate for Payer: Quartz Beloit One Network |
$3,112.13
|
| Rate for Payer: Quartz Commercial |
$4,128.33
|
| Rate for Payer: Quartz Medicare Advantage |
$3,810.77
|
| Rate for Payer: The Alliance Commercial |
$3,175.64
|
| Rate for Payer: WEA Trust Commercial |
$3,493.20
|
| Rate for Payer: WPS Commercial |
$4,704.22
|
|
|
HIP PROSTHESIS AUSTIN-MOORE 52MM 4021-08-52
|
Facility
|
OP
|
$7,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.73 |
| Max. Negotiated Rate |
$6,705.25 |
| Rate for Payer: Aetna Commercial |
$6,559.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,267.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,737.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,644.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,498.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,862.81
|
| Rate for Payer: Cash Price |
$2,102.40
|
| Rate for Payer: Cigna Commercial |
$6,705.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,078.66
|
| Rate for Payer: Health EOS Commercial |
$6,486.60
|
| Rate for Payer: HFN Commercial |
$6,705.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,466.24
|
| Rate for Payer: Multiplan Commercial |
$5,830.66
|
| Rate for Payer: NAPHCARE Commercial |
$4,372.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,705.25
|
| Rate for Payer: Quartz Beloit One Network |
$3,571.28
|
| Rate for Payer: Quartz Commercial |
$4,737.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4,372.99
|
| Rate for Payer: The Alliance Commercial |
$3,644.16
|
| Rate for Payer: WEA Trust Commercial |
$4,008.58
|
| Rate for Payer: WPS Commercial |
$5,398.26
|
|
|
HIP PROSTHESIS AUSTIN-MOORE 52MM 4021-08-52
|
Facility
|
IP
|
$7,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,571.28 |
| Max. Negotiated Rate |
$6,705.25 |
| Rate for Payer: Aetna Commercial |
$6,559.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,267.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,862.81
|
| Rate for Payer: Cash Price |
$2,102.40
|
| Rate for Payer: Cigna Commercial |
$6,705.25
|
| Rate for Payer: Health EOS Commercial |
$6,486.60
|
| Rate for Payer: HFN Commercial |
$6,705.25
|
| Rate for Payer: Multiplan Commercial |
$5,830.66
|
| Rate for Payer: Preferred Network Access Commercial |
$6,705.25
|
| Rate for Payer: Quartz Beloit One Network |
$3,571.28
|
| Rate for Payer: Quartz Commercial |
$4,372.99
|
| Rate for Payer: WEA Trust Commercial |
$4,008.58
|
| Rate for Payer: WPS Commercial |
$5,398.26
|
|
|
HIP PROSTHESIS AUSTIN-MOORE 54MM 4021-08-54
|
Facility
|
OP
|
$7,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.73 |
| Max. Negotiated Rate |
$6,705.25 |
| Rate for Payer: Aetna Commercial |
$6,559.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,267.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,737.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,644.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,498.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,862.81
|
| Rate for Payer: Cash Price |
$2,102.40
|
| Rate for Payer: Cigna Commercial |
$6,705.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,078.66
|
| Rate for Payer: Health EOS Commercial |
$6,486.60
|
| Rate for Payer: HFN Commercial |
$6,705.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,466.24
|
| Rate for Payer: Multiplan Commercial |
$5,830.66
|
| Rate for Payer: NAPHCARE Commercial |
$4,372.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,705.25
|
| Rate for Payer: Quartz Beloit One Network |
$3,571.28
|
| Rate for Payer: Quartz Commercial |
$4,737.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4,372.99
|
| Rate for Payer: The Alliance Commercial |
$3,644.16
|
| Rate for Payer: WEA Trust Commercial |
$4,008.58
|
| Rate for Payer: WPS Commercial |
$5,398.26
|
|
|
HIP PROSTHESIS AUSTIN-MOORE 54MM 4021-08-54
|
Facility
|
IP
|
$7,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,571.28 |
| Max. Negotiated Rate |
$6,705.25 |
| Rate for Payer: Aetna Commercial |
$6,559.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,267.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,862.81
|
| Rate for Payer: Cash Price |
$2,102.40
|
| Rate for Payer: Cigna Commercial |
$6,705.25
|
| Rate for Payer: Health EOS Commercial |
$6,486.60
|
| Rate for Payer: HFN Commercial |
$6,705.25
|
| Rate for Payer: Multiplan Commercial |
$5,830.66
|
| Rate for Payer: Preferred Network Access Commercial |
$6,705.25
|
| Rate for Payer: Quartz Beloit One Network |
$3,571.28
|
| Rate for Payer: Quartz Commercial |
$4,372.99
|
| Rate for Payer: WEA Trust Commercial |
$4,008.58
|
| Rate for Payer: WPS Commercial |
$5,398.26
|
|
|
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC
|
Facility
|
IP
|
$83,120.96
|
|
|
Service Code
|
MSDRG 521
|
| Min. Negotiated Rate |
$22,487.34 |
| Max. Negotiated Rate |
$83,120.96 |
| Rate for Payer: Aetna Managed Medicare |
$22,487.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62,625.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48,001.91
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45,604.95
|
| Rate for Payer: Anthem Medicare Advantage |
$22,487.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22,487.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22,487.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22,487.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50,625.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22,487.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60,722.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22,487.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22,487.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$22,487.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22,487.34
|
| Rate for Payer: NAPHCARE Commercial |
$33,731.01
|
| Rate for Payer: Quartz Medicare Advantage |
$22,487.34
|
| Rate for Payer: The Alliance Commercial |
$83,120.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22,487.34
|
| Rate for Payer: United Healthcare PPO |
$47,273.15
|
| Rate for Payer: Wellcare Medicare |
$22,487.34
|
|
|
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC
|
Facility
|
IP
|
$58,734.00
|
|
|
Service Code
|
MSDRG 522
|
| Min. Negotiated Rate |
$16,724.54 |
| Max. Negotiated Rate |
$58,734.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,724.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46,206.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35,416.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,648.39
|
| Rate for Payer: Anthem Medicare Advantage |
$16,724.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,724.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,724.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,724.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37,352.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,724.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42,835.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,724.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,724.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,724.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,724.54
|
| Rate for Payer: NAPHCARE Commercial |
$25,086.81
|
| Rate for Payer: Quartz Medicare Advantage |
$16,724.54
|
| Rate for Payer: The Alliance Commercial |
$58,734.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,724.54
|
| Rate for Payer: United Healthcare PPO |
$33,347.92
|
| Rate for Payer: Wellcare Medicare |
$16,724.54
|
|
|
HIP SPICA ADULT
|
Facility
|
OP
|
$3,602.00
|
|
| Hospital Charge Code |
3075862
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,048.90 |
| Max. Negotiated Rate |
$3,446.39 |
| Rate for Payer: Aetna Commercial |
$3,371.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,221.63
|
| Rate for Payer: Aetna Managed Medicare |
$1,048.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,434.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,873.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,798.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,985.42
|
| Rate for Payer: Cash Price |
$1,080.60
|
| Rate for Payer: Cigna Commercial |
$3,446.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,096.36
|
| Rate for Payer: Health EOS Commercial |
$3,334.01
|
| Rate for Payer: HFN Commercial |
$3,446.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,809.56
|
| Rate for Payer: Multiplan Commercial |
$2,996.86
|
| Rate for Payer: NAPHCARE Commercial |
$2,247.65
|
| Rate for Payer: Preferred Network Access Commercial |
$3,446.39
|
| Rate for Payer: Quartz Beloit One Network |
$1,835.58
|
| Rate for Payer: Quartz Commercial |
$2,434.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,247.65
|
| Rate for Payer: The Alliance Commercial |
$1,873.04
|
| Rate for Payer: WEA Trust Commercial |
$2,060.34
|
| Rate for Payer: WPS Commercial |
$2,774.62
|
|
|
HIP SPICA ADULT
|
Facility
|
IP
|
$3,602.00
|
|
| Hospital Charge Code |
3075862
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,835.58 |
| Max. Negotiated Rate |
$3,446.39 |
| Rate for Payer: Aetna Commercial |
$3,371.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,221.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,985.42
|
| Rate for Payer: Cash Price |
$1,080.60
|
| Rate for Payer: Cigna Commercial |
$3,446.39
|
| Rate for Payer: Health EOS Commercial |
$3,334.01
|
| Rate for Payer: HFN Commercial |
$3,446.39
|
| Rate for Payer: Multiplan Commercial |
$2,996.86
|
| Rate for Payer: Preferred Network Access Commercial |
$3,446.39
|
| Rate for Payer: Quartz Beloit One Network |
$1,835.58
|
| Rate for Payer: Quartz Commercial |
$2,247.65
|
| Rate for Payer: WEA Trust Commercial |
$2,060.34
|
| Rate for Payer: WPS Commercial |
$2,774.62
|
|
|
HIP SPICA CAST
|
Facility
|
IP
|
$270.00
|
|
| Hospital Charge Code |
2960121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$137.59 |
| Max. Negotiated Rate |
$258.34 |
| Rate for Payer: Aetna Commercial |
$252.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$258.34
|
| Rate for Payer: Health EOS Commercial |
$249.91
|
| Rate for Payer: HFN Commercial |
$258.34
|
| Rate for Payer: Multiplan Commercial |
$224.64
|
| Rate for Payer: Preferred Network Access Commercial |
$258.34
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$168.48
|
| Rate for Payer: WEA Trust Commercial |
$154.44
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
HIP SPICA CAST
|
Facility
|
OP
|
$270.00
|
|
| Hospital Charge Code |
2960121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$78.62 |
| Max. Negotiated Rate |
$258.34 |
| Rate for Payer: Aetna Commercial |
$252.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.49
|
| Rate for Payer: Aetna Managed Medicare |
$78.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$182.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$140.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$134.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$258.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.14
|
| Rate for Payer: Health EOS Commercial |
$249.91
|
| Rate for Payer: HFN Commercial |
$258.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.60
|
| Rate for Payer: Multiplan Commercial |
$224.64
|
| Rate for Payer: NAPHCARE Commercial |
$168.48
|
| Rate for Payer: Preferred Network Access Commercial |
$258.34
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$182.52
|
| Rate for Payer: Quartz Medicare Advantage |
$168.48
|
| Rate for Payer: The Alliance Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$154.44
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
HIP SPICA CHILD
|
Facility
|
IP
|
$2,913.00
|
|
| Hospital Charge Code |
3075861
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,484.46 |
| Max. Negotiated Rate |
$2,787.16 |
| Rate for Payer: Aetna Commercial |
$2,726.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,605.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,605.65
|
| Rate for Payer: Cash Price |
$873.90
|
| Rate for Payer: Cigna Commercial |
$2,787.16
|
| Rate for Payer: Health EOS Commercial |
$2,696.27
|
| Rate for Payer: HFN Commercial |
$2,787.16
|
| Rate for Payer: Multiplan Commercial |
$2,423.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,787.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,484.46
|
| Rate for Payer: Quartz Commercial |
$1,817.71
|
| Rate for Payer: WEA Trust Commercial |
$1,666.24
|
| Rate for Payer: WPS Commercial |
$2,243.88
|
|
|
HIP SPICA CHILD
|
Facility
|
OP
|
$2,913.00
|
|
| Hospital Charge Code |
3075861
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$848.27 |
| Max. Negotiated Rate |
$2,787.16 |
| Rate for Payer: Aetna Commercial |
$2,726.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,605.39
|
| Rate for Payer: Aetna Managed Medicare |
$848.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,969.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,514.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,454.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,605.65
|
| Rate for Payer: Cash Price |
$873.90
|
| Rate for Payer: Cigna Commercial |
$2,787.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,695.37
|
| Rate for Payer: Health EOS Commercial |
$2,696.27
|
| Rate for Payer: HFN Commercial |
$2,787.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,272.14
|
| Rate for Payer: Multiplan Commercial |
$2,423.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,817.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,787.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,484.46
|
| Rate for Payer: Quartz Commercial |
$1,969.19
|
| Rate for Payer: Quartz Medicare Advantage |
$1,817.71
|
| Rate for Payer: The Alliance Commercial |
$1,514.76
|
| Rate for Payer: WEA Trust Commercial |
$1,666.24
|
| Rate for Payer: WPS Commercial |
$2,243.88
|
|
|
HIP SPICA INFANT
|
Facility
|
OP
|
$1,975.00
|
|
| Hospital Charge Code |
3075860
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$575.12 |
| Max. Negotiated Rate |
$1,889.68 |
| Rate for Payer: Aetna Commercial |
$1,848.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,766.44
|
| Rate for Payer: Aetna Managed Medicare |
$575.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,335.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,027.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$985.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,088.62
|
| Rate for Payer: Cash Price |
$592.50
|
| Rate for Payer: Cigna Commercial |
$1,889.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,149.45
|
| Rate for Payer: Health EOS Commercial |
$1,828.06
|
| Rate for Payer: HFN Commercial |
$1,889.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,540.50
|
| Rate for Payer: Multiplan Commercial |
$1,643.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,232.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,889.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,006.46
|
| Rate for Payer: Quartz Commercial |
$1,335.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,232.40
|
| Rate for Payer: The Alliance Commercial |
$1,027.00
|
| Rate for Payer: WEA Trust Commercial |
$1,129.70
|
| Rate for Payer: WPS Commercial |
$1,521.34
|
|
|
HIP SPICA INFANT
|
Facility
|
IP
|
$1,975.00
|
|
| Hospital Charge Code |
3075860
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,006.46 |
| Max. Negotiated Rate |
$1,889.68 |
| Rate for Payer: Aetna Commercial |
$1,848.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,766.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,088.62
|
| Rate for Payer: Cash Price |
$592.50
|
| Rate for Payer: Cigna Commercial |
$1,889.68
|
| Rate for Payer: Health EOS Commercial |
$1,828.06
|
| Rate for Payer: HFN Commercial |
$1,889.68
|
| Rate for Payer: Multiplan Commercial |
$1,643.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,889.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,006.46
|
| Rate for Payer: Quartz Commercial |
$1,232.40
|
| Rate for Payer: WEA Trust Commercial |
$1,129.70
|
| Rate for Payer: WPS Commercial |
$1,521.34
|
|
|
HIP STEM ACCOLADE C CEMENTED SZ 4 6058-0435D
|
Facility
|
IP
|
$8,851.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6153690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,510.47 |
| Max. Negotiated Rate |
$8,468.64 |
| Rate for Payer: Aetna Commercial |
$8,284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,916.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,878.67
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,468.64
|
| Rate for Payer: Health EOS Commercial |
$8,192.49
|
| Rate for Payer: HFN Commercial |
$8,468.64
|
| Rate for Payer: Multiplan Commercial |
$7,364.03
|
| Rate for Payer: Preferred Network Access Commercial |
$8,468.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,510.47
|
| Rate for Payer: Quartz Commercial |
$5,523.02
|
| Rate for Payer: WEA Trust Commercial |
$5,062.77
|
| Rate for Payer: WPS Commercial |
$6,817.93
|
|
|
HIP STEM ACCOLADE C CEMENTED SZ 4 6058-0435D
|
Facility
|
OP
|
$8,851.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6153690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.41 |
| Max. Negotiated Rate |
$8,468.64 |
| Rate for Payer: Aetna Commercial |
$8,284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,916.33
|
| Rate for Payer: Aetna Managed Medicare |
$2,577.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,983.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,602.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,418.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,878.67
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,468.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,151.28
|
| Rate for Payer: Health EOS Commercial |
$8,192.49
|
| Rate for Payer: HFN Commercial |
$8,468.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,903.78
|
| Rate for Payer: Multiplan Commercial |
$7,364.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,523.02
|
| Rate for Payer: Preferred Network Access Commercial |
$8,468.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,510.47
|
| Rate for Payer: Quartz Commercial |
$5,983.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,523.02
|
| Rate for Payer: The Alliance Commercial |
$4,602.52
|
| Rate for Payer: WEA Trust Commercial |
$5,062.77
|
| Rate for Payer: WPS Commercial |
$6,817.93
|
|
|
HIP STEM ACCOLADE C CEMENTED SZ 5 6058-0537D
|
Facility
|
IP
|
$9,209.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,692.91 |
| Max. Negotiated Rate |
$8,811.17 |
| Rate for Payer: Aetna Commercial |
$8,619.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,236.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,076.00
|
| Rate for Payer: Cash Price |
$2,762.70
|
| Rate for Payer: Cigna Commercial |
$8,811.17
|
| Rate for Payer: Health EOS Commercial |
$8,523.85
|
| Rate for Payer: HFN Commercial |
$8,811.17
|
| Rate for Payer: Multiplan Commercial |
$7,661.89
|
| Rate for Payer: Preferred Network Access Commercial |
$8,811.17
|
| Rate for Payer: Quartz Beloit One Network |
$4,692.91
|
| Rate for Payer: Quartz Commercial |
$5,746.42
|
| Rate for Payer: WEA Trust Commercial |
$5,267.55
|
| Rate for Payer: WPS Commercial |
$7,093.69
|
|
|
HIP STEM ACCOLADE C CEMENTED SZ 5 6058-0537D
|
Facility
|
OP
|
$9,209.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.66 |
| Max. Negotiated Rate |
$8,811.17 |
| Rate for Payer: Aetna Commercial |
$8,619.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,236.53
|
| Rate for Payer: Aetna Managed Medicare |
$2,681.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,225.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,788.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,597.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,076.00
|
| Rate for Payer: Cash Price |
$2,762.70
|
| Rate for Payer: Cigna Commercial |
$8,811.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,359.64
|
| Rate for Payer: Health EOS Commercial |
$8,523.85
|
| Rate for Payer: HFN Commercial |
$8,811.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,183.02
|
| Rate for Payer: Multiplan Commercial |
$7,661.89
|
| Rate for Payer: NAPHCARE Commercial |
$5,746.42
|
| Rate for Payer: Preferred Network Access Commercial |
$8,811.17
|
| Rate for Payer: Quartz Beloit One Network |
$4,692.91
|
| Rate for Payer: Quartz Commercial |
$6,225.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,746.42
|
| Rate for Payer: The Alliance Commercial |
$4,788.68
|
| Rate for Payer: WEA Trust Commercial |
$5,267.55
|
| Rate for Payer: WPS Commercial |
$7,093.69
|
|
|
HIP STEM ACCOLADE CEMENTED SZ 2 127 DEG 6057-0230D
|
Facility
|
OP
|
$10,976.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,196.21 |
| Max. Negotiated Rate |
$10,501.84 |
| Rate for Payer: Aetna Commercial |
$10,273.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,816.93
|
| Rate for Payer: Aetna Managed Medicare |
$3,196.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,419.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,707.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,479.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,049.97
|
| Rate for Payer: Cash Price |
$3,292.80
|
| Rate for Payer: Cigna Commercial |
$10,501.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,388.03
|
| Rate for Payer: Health EOS Commercial |
$10,159.39
|
| Rate for Payer: HFN Commercial |
$10,501.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,561.28
|
| Rate for Payer: Multiplan Commercial |
$9,132.03
|
| Rate for Payer: NAPHCARE Commercial |
$6,849.02
|
| Rate for Payer: Preferred Network Access Commercial |
$10,501.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,593.37
|
| Rate for Payer: Quartz Commercial |
$7,419.78
|
| Rate for Payer: Quartz Medicare Advantage |
$6,849.02
|
| Rate for Payer: The Alliance Commercial |
$5,707.52
|
| Rate for Payer: WEA Trust Commercial |
$6,278.27
|
| Rate for Payer: WPS Commercial |
$8,454.81
|
|
|
HIP STEM ACCOLADE CEMENTED SZ 2 127 DEG 6057-0230D
|
Facility
|
IP
|
$10,976.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,593.37 |
| Max. Negotiated Rate |
$10,501.84 |
| Rate for Payer: Aetna Commercial |
$10,273.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,816.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,049.97
|
| Rate for Payer: Cash Price |
$3,292.80
|
| Rate for Payer: Cigna Commercial |
$10,501.84
|
| Rate for Payer: Health EOS Commercial |
$10,159.39
|
| Rate for Payer: HFN Commercial |
$10,501.84
|
| Rate for Payer: Multiplan Commercial |
$9,132.03
|
| Rate for Payer: Preferred Network Access Commercial |
$10,501.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,593.37
|
| Rate for Payer: Quartz Commercial |
$6,849.02
|
| Rate for Payer: WEA Trust Commercial |
$6,278.27
|
| Rate for Payer: WPS Commercial |
$8,454.81
|
|
|
HIP STEM ACCOLADE CEMENTED SZ 3 127 DEG 6057-0335D
|
Facility
|
OP
|
$9,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074873
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,647.88 |
| Max. Negotiated Rate |
$8,700.18 |
| Rate for Payer: Aetna Commercial |
$8,511.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,132.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,647.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,146.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,728.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,539.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,012.06
|
| Rate for Payer: Cash Price |
$2,727.90
|
| Rate for Payer: Cigna Commercial |
$8,700.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,292.13
|
| Rate for Payer: Health EOS Commercial |
$8,416.48
|
| Rate for Payer: HFN Commercial |
$8,700.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,092.54
|
| Rate for Payer: Multiplan Commercial |
$7,565.38
|
| Rate for Payer: NAPHCARE Commercial |
$5,674.03
|
| Rate for Payer: Preferred Network Access Commercial |
$8,700.18
|
| Rate for Payer: Quartz Beloit One Network |
$4,633.79
|
| Rate for Payer: Quartz Commercial |
$6,146.87
|
| Rate for Payer: Quartz Medicare Advantage |
$5,674.03
|
| Rate for Payer: The Alliance Commercial |
$4,728.36
|
| Rate for Payer: WEA Trust Commercial |
$5,201.20
|
| Rate for Payer: WPS Commercial |
$7,004.34
|
|
|
HIP STEM ACCOLADE CEMENTED SZ 3 127 DEG 6057-0335D
|
Facility
|
IP
|
$9,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074873
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,633.79 |
| Max. Negotiated Rate |
$8,700.18 |
| Rate for Payer: Aetna Commercial |
$8,511.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,132.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,012.06
|
| Rate for Payer: Cash Price |
$2,727.90
|
| Rate for Payer: Cigna Commercial |
$8,700.18
|
| Rate for Payer: Health EOS Commercial |
$8,416.48
|
| Rate for Payer: HFN Commercial |
$8,700.18
|
| Rate for Payer: Multiplan Commercial |
$7,565.38
|
| Rate for Payer: Preferred Network Access Commercial |
$8,700.18
|
| Rate for Payer: Quartz Beloit One Network |
$4,633.79
|
| Rate for Payer: Quartz Commercial |
$5,674.03
|
| Rate for Payer: WEA Trust Commercial |
$5,201.20
|
| Rate for Payer: WPS Commercial |
$7,004.34
|
|
|
HIP STEM ACCOLADE CEMENTED SZ 4 127 DEG 6057-0435D
|
Facility
|
OP
|
$9,205.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074737
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,680.50 |
| Max. Negotiated Rate |
$8,807.34 |
| Rate for Payer: Aetna Commercial |
$8,615.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,232.95
|
| Rate for Payer: Aetna Managed Medicare |
$2,680.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,222.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,786.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,595.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,073.80
|
| Rate for Payer: Cash Price |
$2,761.50
|
| Rate for Payer: Cigna Commercial |
$8,807.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,357.31
|
| Rate for Payer: Health EOS Commercial |
$8,520.15
|
| Rate for Payer: HFN Commercial |
$8,807.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,179.90
|
| Rate for Payer: Multiplan Commercial |
$7,658.56
|
| Rate for Payer: NAPHCARE Commercial |
$5,743.92
|
| Rate for Payer: Preferred Network Access Commercial |
$8,807.34
|
| Rate for Payer: Quartz Beloit One Network |
$4,690.87
|
| Rate for Payer: Quartz Commercial |
$6,222.58
|
| Rate for Payer: Quartz Medicare Advantage |
$5,743.92
|
| Rate for Payer: The Alliance Commercial |
$4,786.60
|
| Rate for Payer: WEA Trust Commercial |
$5,265.26
|
| Rate for Payer: WPS Commercial |
$7,090.61
|
|
