|
HUMERAL HEAD ECLIPSE 41/18 AR-9341-18
|
Facility
|
IP
|
$7,672.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5885660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,909.65 |
| Max. Negotiated Rate |
$7,340.57 |
| Rate for Payer: Aetna Commercial |
$7,180.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.81
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,340.57
|
| Rate for Payer: Health EOS Commercial |
$7,101.20
|
| Rate for Payer: HFN Commercial |
$7,340.57
|
| Rate for Payer: Multiplan Commercial |
$6,383.10
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.57
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.65
|
| Rate for Payer: Quartz Commercial |
$4,787.33
|
| Rate for Payer: WEA Trust Commercial |
$4,388.38
|
| Rate for Payer: WPS Commercial |
$5,909.74
|
|
|
HUMERAL HEAD ECLIPSE 41/18 AR-9341-18
|
Facility
|
OP
|
$7,672.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5885660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,234.09 |
| Max. Negotiated Rate |
$7,340.57 |
| Rate for Payer: Aetna Commercial |
$7,180.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,234.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,186.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,989.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,829.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.81
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,340.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,465.10
|
| Rate for Payer: Health EOS Commercial |
$7,101.20
|
| Rate for Payer: HFN Commercial |
$7,340.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,984.16
|
| Rate for Payer: Multiplan Commercial |
$6,383.10
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.33
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.57
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.65
|
| Rate for Payer: Quartz Commercial |
$5,186.27
|
| Rate for Payer: Quartz Medicare Advantage |
$4,787.33
|
| Rate for Payer: The Alliance Commercial |
$3,989.44
|
| Rate for Payer: WEA Trust Commercial |
$4,388.38
|
| Rate for Payer: WPS Commercial |
$5,909.74
|
|
|
HUMERAL HEAD ECLIPSE 47/20 AR-9347-20
|
Facility
|
IP
|
$7,672.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5617681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,909.65 |
| Max. Negotiated Rate |
$7,340.57 |
| Rate for Payer: Aetna Commercial |
$7,180.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.81
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,340.57
|
| Rate for Payer: Health EOS Commercial |
$7,101.20
|
| Rate for Payer: HFN Commercial |
$7,340.57
|
| Rate for Payer: Multiplan Commercial |
$6,383.10
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.57
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.65
|
| Rate for Payer: Quartz Commercial |
$4,787.33
|
| Rate for Payer: WEA Trust Commercial |
$4,388.38
|
| Rate for Payer: WPS Commercial |
$5,909.74
|
|
|
HUMERAL HEAD ECLIPSE 47/20 AR-9347-20
|
Facility
|
OP
|
$7,672.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5617681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,234.09 |
| Max. Negotiated Rate |
$7,340.57 |
| Rate for Payer: Aetna Commercial |
$7,180.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,234.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,186.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,989.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,829.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.81
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,340.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,465.10
|
| Rate for Payer: Health EOS Commercial |
$7,101.20
|
| Rate for Payer: HFN Commercial |
$7,340.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,984.16
|
| Rate for Payer: Multiplan Commercial |
$6,383.10
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.33
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.57
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.65
|
| Rate for Payer: Quartz Commercial |
$5,186.27
|
| Rate for Payer: Quartz Medicare Advantage |
$4,787.33
|
| Rate for Payer: The Alliance Commercial |
$3,989.44
|
| Rate for Payer: WEA Trust Commercial |
$4,388.38
|
| Rate for Payer: WPS Commercial |
$5,909.74
|
|
|
HUMERAL HEAD ECLIPSE 51/21 AR-9351-21
|
Facility
|
OP
|
$7,377.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6151661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,148.18 |
| Max. Negotiated Rate |
$7,058.31 |
| Rate for Payer: Aetna Commercial |
$6,904.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,597.99
|
| Rate for Payer: Aetna Managed Medicare |
$2,148.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,986.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,836.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,682.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,066.20
|
| Rate for Payer: Cash Price |
$2,213.10
|
| Rate for Payer: Cigna Commercial |
$7,058.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,293.41
|
| Rate for Payer: Health EOS Commercial |
$6,828.15
|
| Rate for Payer: HFN Commercial |
$7,058.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,754.06
|
| Rate for Payer: Multiplan Commercial |
$6,137.66
|
| Rate for Payer: NAPHCARE Commercial |
$4,603.25
|
| Rate for Payer: Preferred Network Access Commercial |
$7,058.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,759.32
|
| Rate for Payer: Quartz Commercial |
$4,986.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,603.25
|
| Rate for Payer: The Alliance Commercial |
$3,836.04
|
| Rate for Payer: WEA Trust Commercial |
$4,219.64
|
| Rate for Payer: WPS Commercial |
$5,682.50
|
|
|
HUMERAL HEAD ECLIPSE 51/21 AR-9351-21
|
Facility
|
IP
|
$7,377.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6151661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,759.32 |
| Max. Negotiated Rate |
$7,058.31 |
| Rate for Payer: Aetna Commercial |
$6,904.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,597.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,066.20
|
| Rate for Payer: Cash Price |
$2,213.10
|
| Rate for Payer: Cigna Commercial |
$7,058.31
|
| Rate for Payer: Health EOS Commercial |
$6,828.15
|
| Rate for Payer: HFN Commercial |
$7,058.31
|
| Rate for Payer: Multiplan Commercial |
$6,137.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7,058.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,759.32
|
| Rate for Payer: Quartz Commercial |
$4,603.25
|
| Rate for Payer: WEA Trust Commercial |
$4,219.64
|
| Rate for Payer: WPS Commercial |
$5,682.50
|
|
|
HUMERAL HEAD UNIVERS II 44/17 AR-9144-17P
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6179096
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,409.68 |
| Max. Negotiated Rate |
$7,917.52 |
| Rate for Payer: Aetna Commercial |
$7,745.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,401.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,409.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,593.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,303.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,130.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,561.18
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,917.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,816.05
|
| Rate for Payer: Health EOS Commercial |
$7,659.34
|
| Rate for Payer: HFN Commercial |
$7,917.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,454.50
|
| Rate for Payer: Multiplan Commercial |
$6,884.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,163.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,917.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,216.94
|
| Rate for Payer: Quartz Commercial |
$5,593.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,163.60
|
| Rate for Payer: The Alliance Commercial |
$4,303.00
|
| Rate for Payer: WEA Trust Commercial |
$4,733.30
|
| Rate for Payer: WPS Commercial |
$6,374.23
|
|
|
HUMERAL HEAD UNIVERS II 44/17 AR-9144-17P
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6179096
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,216.94 |
| Max. Negotiated Rate |
$7,917.52 |
| Rate for Payer: Aetna Commercial |
$7,745.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,401.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,561.18
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,917.52
|
| Rate for Payer: Health EOS Commercial |
$7,659.34
|
| Rate for Payer: HFN Commercial |
$7,917.52
|
| Rate for Payer: Multiplan Commercial |
$6,884.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,917.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,216.94
|
| Rate for Payer: Quartz Commercial |
$5,163.60
|
| Rate for Payer: WEA Trust Commercial |
$4,733.30
|
| Rate for Payer: WPS Commercial |
$6,374.23
|
|
|
HUMERAL HEAD UNIVERS II 44/19 AR-9144-19P
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4518771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,216.94 |
| Max. Negotiated Rate |
$7,917.52 |
| Rate for Payer: Aetna Commercial |
$7,745.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,401.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,561.18
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,917.52
|
| Rate for Payer: Health EOS Commercial |
$7,659.34
|
| Rate for Payer: HFN Commercial |
$7,917.52
|
| Rate for Payer: Multiplan Commercial |
$6,884.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,917.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,216.94
|
| Rate for Payer: Quartz Commercial |
$5,163.60
|
| Rate for Payer: WEA Trust Commercial |
$4,733.30
|
| Rate for Payer: WPS Commercial |
$6,374.23
|
|
|
HUMERAL HEAD UNIVERS II 44/19 AR-9144-19P
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4518771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,409.68 |
| Max. Negotiated Rate |
$7,917.52 |
| Rate for Payer: Aetna Commercial |
$7,745.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,401.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,409.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,593.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,303.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,130.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,561.18
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,917.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,816.05
|
| Rate for Payer: Health EOS Commercial |
$7,659.34
|
| Rate for Payer: HFN Commercial |
$7,917.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,454.50
|
| Rate for Payer: Multiplan Commercial |
$6,884.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,163.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,917.52
|
| Rate for Payer: Quartz Beloit One Network |
$4,216.94
|
| Rate for Payer: Quartz Commercial |
$5,593.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,163.60
|
| Rate for Payer: The Alliance Commercial |
$4,303.00
|
| Rate for Payer: WEA Trust Commercial |
$4,733.30
|
| Rate for Payer: WPS Commercial |
$6,374.23
|
|
|
HUMERAL INSERT COMBINATION 33 +3 / 36 AR-9503-3336-3
|
Facility
|
OP
|
$4,799.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6185034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,397.47 |
| Max. Negotiated Rate |
$4,591.68 |
| Rate for Payer: Aetna Commercial |
$4,491.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,292.23
|
| Rate for Payer: Aetna Managed Medicare |
$1,397.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,244.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,495.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,395.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,645.21
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,591.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,793.02
|
| Rate for Payer: Health EOS Commercial |
$4,441.95
|
| Rate for Payer: HFN Commercial |
$4,591.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,743.22
|
| Rate for Payer: Multiplan Commercial |
$3,992.77
|
| Rate for Payer: NAPHCARE Commercial |
$2,994.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,591.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,445.57
|
| Rate for Payer: Quartz Commercial |
$3,244.12
|
| Rate for Payer: Quartz Medicare Advantage |
$2,994.58
|
| Rate for Payer: The Alliance Commercial |
$2,495.48
|
| Rate for Payer: WEA Trust Commercial |
$2,745.03
|
| Rate for Payer: WPS Commercial |
$3,696.67
|
|
|
HUMERAL INSERT COMBINATION 33 +3 / 36 AR-9503-3336-3
|
Facility
|
IP
|
$4,799.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6185034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,445.57 |
| Max. Negotiated Rate |
$4,591.68 |
| Rate for Payer: Aetna Commercial |
$4,491.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,292.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,645.21
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,591.68
|
| Rate for Payer: Health EOS Commercial |
$4,441.95
|
| Rate for Payer: HFN Commercial |
$4,591.68
|
| Rate for Payer: Multiplan Commercial |
$3,992.77
|
| Rate for Payer: Preferred Network Access Commercial |
$4,591.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,445.57
|
| Rate for Payer: Quartz Commercial |
$2,994.58
|
| Rate for Payer: WEA Trust Commercial |
$2,745.03
|
| Rate for Payer: WPS Commercial |
$3,696.67
|
|
|
HUMERAL INSERT COMBO 36 +3 / 33 AR-9503-3633-3
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603641
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,751.33 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$5,053.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,828.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,975.93
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$5,165.76
|
| Rate for Payer: Health EOS Commercial |
$4,997.31
|
| Rate for Payer: HFN Commercial |
$5,165.76
|
| Rate for Payer: Multiplan Commercial |
$4,491.97
|
| Rate for Payer: Preferred Network Access Commercial |
$5,165.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,751.33
|
| Rate for Payer: Quartz Commercial |
$3,368.98
|
| Rate for Payer: WEA Trust Commercial |
$3,088.23
|
| Rate for Payer: WPS Commercial |
$4,158.85
|
|
|
HUMERAL INSERT COMBO 36 +3 / 33 AR-9503-3633-3
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603641
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,572.19 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$5,053.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,828.87
|
| Rate for Payer: Aetna Managed Medicare |
$1,572.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,649.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,807.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,695.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,975.93
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$5,165.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,142.22
|
| Rate for Payer: Health EOS Commercial |
$4,997.31
|
| Rate for Payer: HFN Commercial |
$5,165.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,211.22
|
| Rate for Payer: Multiplan Commercial |
$4,491.97
|
| Rate for Payer: NAPHCARE Commercial |
$3,368.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,165.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,751.33
|
| Rate for Payer: Quartz Commercial |
$3,649.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,368.98
|
| Rate for Payer: The Alliance Commercial |
$2,807.48
|
| Rate for Payer: WEA Trust Commercial |
$3,088.23
|
| Rate for Payer: WPS Commercial |
$4,158.85
|
|
|
HUMERAL INSERT COMBO 36 +3 / 39 AR-9503-3639-3
|
Facility
|
IP
|
$5,191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,645.33 |
| Max. Negotiated Rate |
$4,966.75 |
| Rate for Payer: Aetna Commercial |
$4,858.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,642.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,861.28
|
| Rate for Payer: Cash Price |
$1,557.30
|
| Rate for Payer: Cigna Commercial |
$4,966.75
|
| Rate for Payer: Health EOS Commercial |
$4,804.79
|
| Rate for Payer: HFN Commercial |
$4,966.75
|
| Rate for Payer: Multiplan Commercial |
$4,318.91
|
| Rate for Payer: Preferred Network Access Commercial |
$4,966.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,645.33
|
| Rate for Payer: Quartz Commercial |
$3,239.18
|
| Rate for Payer: WEA Trust Commercial |
$2,969.25
|
| Rate for Payer: WPS Commercial |
$3,998.63
|
|
|
HUMERAL INSERT COMBO 36 +3 / 39 AR-9503-3639-3
|
Facility
|
OP
|
$5,191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,511.62 |
| Max. Negotiated Rate |
$4,966.75 |
| Rate for Payer: Aetna Commercial |
$4,858.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,642.83
|
| Rate for Payer: Aetna Managed Medicare |
$1,511.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,509.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,699.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,591.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,861.28
|
| Rate for Payer: Cash Price |
$1,557.30
|
| Rate for Payer: Cigna Commercial |
$4,966.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,021.16
|
| Rate for Payer: Health EOS Commercial |
$4,804.79
|
| Rate for Payer: HFN Commercial |
$4,966.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,048.98
|
| Rate for Payer: Multiplan Commercial |
$4,318.91
|
| Rate for Payer: NAPHCARE Commercial |
$3,239.18
|
| Rate for Payer: Preferred Network Access Commercial |
$4,966.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,645.33
|
| Rate for Payer: Quartz Commercial |
$3,509.12
|
| Rate for Payer: Quartz Medicare Advantage |
$3,239.18
|
| Rate for Payer: The Alliance Commercial |
$2,699.32
|
| Rate for Payer: WEA Trust Commercial |
$2,969.25
|
| Rate for Payer: WPS Commercial |
$3,998.63
|
|
|
HUMERAL INSERT COMBO 36 +6 / 33 AR-9503-3633-6
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,751.33 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$5,053.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,828.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,975.93
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$5,165.76
|
| Rate for Payer: Health EOS Commercial |
$4,997.31
|
| Rate for Payer: HFN Commercial |
$5,165.76
|
| Rate for Payer: Multiplan Commercial |
$4,491.97
|
| Rate for Payer: Preferred Network Access Commercial |
$5,165.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,751.33
|
| Rate for Payer: Quartz Commercial |
$3,368.98
|
| Rate for Payer: WEA Trust Commercial |
$3,088.23
|
| Rate for Payer: WPS Commercial |
$4,158.85
|
|
|
HUMERAL INSERT COMBO 36 +6 / 33 AR-9503-3633-6
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,572.19 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$5,053.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,828.87
|
| Rate for Payer: Aetna Managed Medicare |
$1,572.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,649.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,807.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,695.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,975.93
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$5,165.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,142.22
|
| Rate for Payer: Health EOS Commercial |
$4,997.31
|
| Rate for Payer: HFN Commercial |
$5,165.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,211.22
|
| Rate for Payer: Multiplan Commercial |
$4,491.97
|
| Rate for Payer: NAPHCARE Commercial |
$3,368.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,165.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,751.33
|
| Rate for Payer: Quartz Commercial |
$3,649.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,368.98
|
| Rate for Payer: The Alliance Commercial |
$2,807.48
|
| Rate for Payer: WEA Trust Commercial |
$3,088.23
|
| Rate for Payer: WPS Commercial |
$4,158.85
|
|
|
HUMERAL INSERT CONSTRAINED COMBO 33 +3C / 36 AR-9503-3336-3C
|
Facility
|
IP
|
$4,799.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6200957
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,445.57 |
| Max. Negotiated Rate |
$4,591.68 |
| Rate for Payer: Aetna Commercial |
$4,491.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,292.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,645.21
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,591.68
|
| Rate for Payer: Health EOS Commercial |
$4,441.95
|
| Rate for Payer: HFN Commercial |
$4,591.68
|
| Rate for Payer: Multiplan Commercial |
$3,992.77
|
| Rate for Payer: Preferred Network Access Commercial |
$4,591.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,445.57
|
| Rate for Payer: Quartz Commercial |
$2,994.58
|
| Rate for Payer: WEA Trust Commercial |
$2,745.03
|
| Rate for Payer: WPS Commercial |
$3,696.67
|
|
|
HUMERAL INSERT CONSTRAINED COMBO 33 +3C / 36 AR-9503-3336-3C
|
Facility
|
OP
|
$4,799.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6200957
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,397.47 |
| Max. Negotiated Rate |
$4,591.68 |
| Rate for Payer: Aetna Commercial |
$4,491.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,292.23
|
| Rate for Payer: Aetna Managed Medicare |
$1,397.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,244.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,495.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,395.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,645.21
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,591.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,793.02
|
| Rate for Payer: Health EOS Commercial |
$4,441.95
|
| Rate for Payer: HFN Commercial |
$4,591.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,743.22
|
| Rate for Payer: Multiplan Commercial |
$3,992.77
|
| Rate for Payer: NAPHCARE Commercial |
$2,994.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,591.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,445.57
|
| Rate for Payer: Quartz Commercial |
$3,244.12
|
| Rate for Payer: Quartz Medicare Advantage |
$2,994.58
|
| Rate for Payer: The Alliance Commercial |
$2,495.48
|
| Rate for Payer: WEA Trust Commercial |
$2,745.03
|
| Rate for Payer: WPS Commercial |
$3,696.67
|
|
|
HUMERAL INSERT CONSTRAINED COMBO 33 +6C / 33 AR-9503-3336-6C
|
Facility
|
OP
|
$4,799.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6182329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,397.47 |
| Max. Negotiated Rate |
$4,591.68 |
| Rate for Payer: Aetna Commercial |
$4,491.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,292.23
|
| Rate for Payer: Aetna Managed Medicare |
$1,397.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,244.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,495.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,395.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,645.21
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,591.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,793.02
|
| Rate for Payer: Health EOS Commercial |
$4,441.95
|
| Rate for Payer: HFN Commercial |
$4,591.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,743.22
|
| Rate for Payer: Multiplan Commercial |
$3,992.77
|
| Rate for Payer: NAPHCARE Commercial |
$2,994.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,591.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,445.57
|
| Rate for Payer: Quartz Commercial |
$3,244.12
|
| Rate for Payer: Quartz Medicare Advantage |
$2,994.58
|
| Rate for Payer: The Alliance Commercial |
$2,495.48
|
| Rate for Payer: WEA Trust Commercial |
$2,745.03
|
| Rate for Payer: WPS Commercial |
$3,696.67
|
|
|
HUMERAL INSERT CONSTRAINED COMBO 33 +6C / 33 AR-9503-3336-6C
|
Facility
|
IP
|
$4,799.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6182329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,445.57 |
| Max. Negotiated Rate |
$4,591.68 |
| Rate for Payer: Aetna Commercial |
$4,491.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,292.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,645.21
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,591.68
|
| Rate for Payer: Health EOS Commercial |
$4,441.95
|
| Rate for Payer: HFN Commercial |
$4,591.68
|
| Rate for Payer: Multiplan Commercial |
$3,992.77
|
| Rate for Payer: Preferred Network Access Commercial |
$4,591.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,445.57
|
| Rate for Payer: Quartz Commercial |
$2,994.58
|
| Rate for Payer: WEA Trust Commercial |
$2,745.03
|
| Rate for Payer: WPS Commercial |
$3,696.67
|
|
|
HUMERAL INSERT CONSTRAINED COMBO 36 +3C / 33 AR-9503-3633-3C
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,572.19 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$5,053.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,828.87
|
| Rate for Payer: Aetna Managed Medicare |
$1,572.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,649.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,807.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,695.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,975.93
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$5,165.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,142.22
|
| Rate for Payer: Health EOS Commercial |
$4,997.31
|
| Rate for Payer: HFN Commercial |
$5,165.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,211.22
|
| Rate for Payer: Multiplan Commercial |
$4,491.97
|
| Rate for Payer: NAPHCARE Commercial |
$3,368.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,165.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,751.33
|
| Rate for Payer: Quartz Commercial |
$3,649.72
|
| Rate for Payer: Quartz Medicare Advantage |
$3,368.98
|
| Rate for Payer: The Alliance Commercial |
$2,807.48
|
| Rate for Payer: WEA Trust Commercial |
$3,088.23
|
| Rate for Payer: WPS Commercial |
$4,158.85
|
|
|
HUMERAL INSERT CONSTRAINED COMBO 36 +3C / 33 AR-9503-3633-3C
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5496848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,751.33 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$5,053.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,828.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,975.93
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$5,165.76
|
| Rate for Payer: Health EOS Commercial |
$4,997.31
|
| Rate for Payer: HFN Commercial |
$5,165.76
|
| Rate for Payer: Multiplan Commercial |
$4,491.97
|
| Rate for Payer: Preferred Network Access Commercial |
$5,165.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,751.33
|
| Rate for Payer: Quartz Commercial |
$3,368.98
|
| Rate for Payer: WEA Trust Commercial |
$3,088.23
|
| Rate for Payer: WPS Commercial |
$4,158.85
|
|
|
HUMERAL INSERT S/36 +3 AR-9503S-03C
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4240357
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,751.33 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$5,053.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,828.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,975.93
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$5,165.76
|
| Rate for Payer: Health EOS Commercial |
$4,997.31
|
| Rate for Payer: HFN Commercial |
$5,165.76
|
| Rate for Payer: Multiplan Commercial |
$4,491.97
|
| Rate for Payer: Preferred Network Access Commercial |
$5,165.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,751.33
|
| Rate for Payer: Quartz Commercial |
$3,368.98
|
| Rate for Payer: WEA Trust Commercial |
$3,088.23
|
| Rate for Payer: WPS Commercial |
$4,158.85
|
|
