|
HUMERAL INSERT S/36 +3 AR-9503S-03C
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4240357
|
|
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 S/36 +3 TO FIT IN 36 CUP AR-9503S-03
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519226
|
|
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 TO FIT IN 36 CUP AR-9503S-03
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519226
|
|
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 S/36 +6 TO FIT 36 CUP AR-9503S-06
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4317080
|
|
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 +6 TO FIT 36 CUP AR-9503S-06
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4317080
|
|
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 S/36 +6 TO FIT 36 CUP CONSTRAINT AR-9503S-06C
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4317081
|
|
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 +6 TO FIT 36 CUP CONSTRAINT AR-9503S-06C
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4317081
|
|
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 UNIVERSAL L/42 +3 CONSTRAINED AR-9503L-03C
|
Facility
|
IP
|
$5,191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5611637
|
|
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 UNIVERSAL L/42 +3 CONSTRAINED AR-9503L-03C
|
Facility
|
OP
|
$5,191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5611637
|
|
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 UNIVERSAL L/42 +3 TO FIT 42 CUP AR-9503L-03
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4268736
|
|
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 UNIVERSAL L/42 +3 TO FIT 42 CUP AR-9503L-03
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4268736
|
|
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 UNIVERSAL L/42 +6 CONSTRAINED AR-9503L-06C
|
Facility
|
IP
|
$4,991.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6170103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,543.41 |
| Max. Negotiated Rate |
$4,775.39 |
| Rate for Payer: Aetna Commercial |
$4,671.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,463.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,751.04
|
| Rate for Payer: Cash Price |
$1,497.30
|
| Rate for Payer: Cigna Commercial |
$4,775.39
|
| Rate for Payer: Health EOS Commercial |
$4,619.67
|
| Rate for Payer: HFN Commercial |
$4,775.39
|
| Rate for Payer: Multiplan Commercial |
$4,152.51
|
| Rate for Payer: Preferred Network Access Commercial |
$4,775.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,543.41
|
| Rate for Payer: Quartz Commercial |
$3,114.38
|
| Rate for Payer: WEA Trust Commercial |
$2,854.85
|
| Rate for Payer: WPS Commercial |
$3,844.57
|
|
|
HUMERAL INSERT UNIVERSAL L/42 +6 CONSTRAINED AR-9503L-06C
|
Facility
|
OP
|
$4,991.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6170103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,453.38 |
| Max. Negotiated Rate |
$4,775.39 |
| Rate for Payer: Aetna Commercial |
$4,671.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,463.95
|
| Rate for Payer: Aetna Managed Medicare |
$1,453.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,373.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,595.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,491.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,751.04
|
| Rate for Payer: Cash Price |
$1,497.30
|
| Rate for Payer: Cigna Commercial |
$4,775.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,904.76
|
| Rate for Payer: Health EOS Commercial |
$4,619.67
|
| Rate for Payer: HFN Commercial |
$4,775.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,892.98
|
| Rate for Payer: Multiplan Commercial |
$4,152.51
|
| Rate for Payer: NAPHCARE Commercial |
$3,114.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,775.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,543.41
|
| Rate for Payer: Quartz Commercial |
$3,373.92
|
| Rate for Payer: Quartz Medicare Advantage |
$3,114.38
|
| Rate for Payer: The Alliance Commercial |
$2,595.32
|
| Rate for Payer: WEA Trust Commercial |
$2,854.85
|
| Rate for Payer: WPS Commercial |
$3,844.57
|
|
|
HUMERAL INSERT UNIVERSAL L/42 +6 TO FIT 42 CUP AR-9503L-06
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5190742
|
|
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 UNIVERSAL L/42 +6 TO FIT 42 CUP AR-9503L-06
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5190742
|
|
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 UNIVERSAL M/39 +6 TO FIT 39 CUP AR-9503M-06
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4740611
|
|
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 UNIVERSAL M/39 +6 TO FIT 39 CUP AR-9503M-06
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4740611
|
|
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 UNIVERSAL M/39 +6 TO FIT 39 CUP CONSTRAINT AR-9503M-06C
|
Facility
|
IP
|
$5,191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5617773
|
|
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 UNIVERSAL M/39 +6 TO FIT 39 CUP CONSTRAINT AR-9503M-06C
|
Facility
|
OP
|
$5,191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5617773
|
|
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 UNIVERS REVERS M/39 +3 TO FIT 39 CUP AR-9503M-03
|
Facility
|
OP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4220571
|
|
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 UNIVERS REVERS M/39 +3 TO FIT 39 CUP AR-9503M-03
|
Facility
|
IP
|
$5,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4220571
|
|
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 UNIVERS REVERS M/39 +3 TO FIT 39 CUP CONSTRAINT AR-9503M-03C
|
Facility
|
OP
|
$5,191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5627660
|
|
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 UNIVERS REVERS M/39 +3 TO FIT 39 CUP CONSTRAINT AR-9503M-03C
|
Facility
|
IP
|
$5,191.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5627660
|
|
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 XS/33 +3 AR-9503XS-03
|
Facility
|
OP
|
$4,799.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6180302
|
|
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 XS/33 +3 AR-9503XS-03
|
Facility
|
IP
|
$4,799.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6180302
|
|
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
|
|
