|
HUMERAL HEAD COCR 50/18.75
|
Facility
|
IP
|
$4,101.00
|
|
| Hospital Charge Code |
2966253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,009.49 |
| Max. Negotiated Rate |
$3,772.92 |
| Rate for Payer: Aetna Commercial |
$3,690.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,526.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,173.53
|
| Rate for Payer: Cash Price |
$1,230.30
|
| Rate for Payer: Cigna Commercial |
$3,772.92
|
| Rate for Payer: Health EOS Commercial |
$3,649.89
|
| Rate for Payer: HFN Commercial |
$3,772.92
|
| Rate for Payer: Multiplan Commercial |
$3,280.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,460.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,772.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.49
|
| Rate for Payer: Quartz Commercial |
$2,460.60
|
| Rate for Payer: WEA Trust Commercial |
$2,255.55
|
| Rate for Payer: WPS Commercial |
$3,037.61
|
|
|
HUMERAL HEAD ECLIPSE 39/16 AR-9339-16
|
Facility
|
OP
|
$7,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6178084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,986.04 |
| Max. Negotiated Rate |
$28,372.00 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,986.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,610.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,546.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,404.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,969.24
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,319.75
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,610.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,255.80
|
| Rate for Payer: The Alliance Commercial |
$28,372.00
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
HUMERAL HEAD ECLIPSE 39/16 AR-9339-16
|
Facility
|
IP
|
$7,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6178084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,475.57 |
| Max. Negotiated Rate |
$6,525.56 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,255.80
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
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 |
$2,148.16 |
| Max. Negotiated Rate |
$30,688.00 |
| Rate for Payer: Aetna Commercial |
$6,904.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,597.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,148.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,986.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,836.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,682.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,066.16
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,058.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,293.25
|
| Rate for Payer: Health EOS Commercial |
$6,828.08
|
| Rate for Payer: HFN Commercial |
$7,058.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,754.00
|
| Rate for Payer: Multiplan Commercial |
$6,137.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,603.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,058.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,759.28
|
| Rate for Payer: Quartz Commercial |
$4,986.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,603.20
|
| Rate for Payer: The Alliance Commercial |
$30,688.00
|
| Rate for Payer: WEA Trust Commercial |
$4,219.60
|
| Rate for Payer: WPS Commercial |
$5,682.65
|
|
|
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 |
$3,759.28 |
| Max. Negotiated Rate |
$7,058.24 |
| Rate for Payer: Aetna Commercial |
$6,904.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,597.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,066.16
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,058.24
|
| Rate for Payer: Health EOS Commercial |
$6,828.08
|
| Rate for Payer: HFN Commercial |
$7,058.24
|
| Rate for Payer: Multiplan Commercial |
$6,137.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,603.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,058.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,759.28
|
| Rate for Payer: Quartz Commercial |
$4,603.20
|
| Rate for Payer: WEA Trust Commercial |
$4,219.60
|
| Rate for Payer: WPS Commercial |
$5,682.65
|
|
|
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 |
$2,148.16 |
| Max. Negotiated Rate |
$30,688.00 |
| Rate for Payer: Aetna Commercial |
$6,904.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,597.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,148.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,986.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,836.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,682.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,066.16
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,058.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,293.25
|
| Rate for Payer: Health EOS Commercial |
$6,828.08
|
| Rate for Payer: HFN Commercial |
$7,058.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,754.00
|
| Rate for Payer: Multiplan Commercial |
$6,137.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,603.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,058.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,759.28
|
| Rate for Payer: Quartz Commercial |
$4,986.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,603.20
|
| Rate for Payer: The Alliance Commercial |
$30,688.00
|
| Rate for Payer: WEA Trust Commercial |
$4,219.60
|
| Rate for Payer: WPS Commercial |
$5,682.65
|
|
|
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 |
$3,759.28 |
| Max. Negotiated Rate |
$7,058.24 |
| Rate for Payer: Aetna Commercial |
$6,904.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,597.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,066.16
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,058.24
|
| Rate for Payer: Health EOS Commercial |
$6,828.08
|
| Rate for Payer: HFN Commercial |
$7,058.24
|
| Rate for Payer: Multiplan Commercial |
$6,137.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,603.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,058.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,759.28
|
| Rate for Payer: Quartz Commercial |
$4,603.20
|
| Rate for Payer: WEA Trust Commercial |
$4,219.60
|
| Rate for Payer: WPS Commercial |
$5,682.65
|
|
|
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 |
$3,614.73 |
| Max. Negotiated Rate |
$6,786.84 |
| Rate for Payer: Aetna Commercial |
$6,639.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,344.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,909.81
|
| Rate for Payer: Cash Price |
$2,213.10
|
| Rate for Payer: Cigna Commercial |
$6,786.84
|
| Rate for Payer: Health EOS Commercial |
$6,565.53
|
| Rate for Payer: HFN Commercial |
$6,786.84
|
| Rate for Payer: Multiplan Commercial |
$5,901.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,426.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,786.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,614.73
|
| Rate for Payer: Quartz Commercial |
$4,426.20
|
| Rate for Payer: WEA Trust Commercial |
$4,057.35
|
| Rate for Payer: WPS Commercial |
$5,464.14
|
|
|
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 |
$2,065.56 |
| Max. Negotiated Rate |
$29,508.00 |
| Rate for Payer: Aetna Commercial |
$6,639.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,344.22
|
| Rate for Payer: Aetna Managed Medicare |
$2,065.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,795.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,688.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,540.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,909.81
|
| Rate for Payer: Cash Price |
$2,213.10
|
| Rate for Payer: Cigna Commercial |
$6,786.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,128.17
|
| Rate for Payer: Health EOS Commercial |
$6,565.53
|
| Rate for Payer: HFN Commercial |
$6,786.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,532.75
|
| Rate for Payer: Multiplan Commercial |
$5,901.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,426.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,786.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,614.73
|
| Rate for Payer: Quartz Commercial |
$4,795.05
|
| Rate for Payer: Quartz Medicare Advantage |
$4,426.20
|
| Rate for Payer: The Alliance Commercial |
$29,508.00
|
| Rate for Payer: WEA Trust Commercial |
$4,057.35
|
| Rate for Payer: WPS Commercial |
$5,464.14
|
|
|
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 |
$2,317.00 |
| Max. Negotiated Rate |
$33,100.00 |
| Rate for Payer: Aetna Commercial |
$7,447.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,116.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,317.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,378.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,137.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,972.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,385.75
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,613.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,630.69
|
| Rate for Payer: Health EOS Commercial |
$7,364.75
|
| Rate for Payer: HFN Commercial |
$7,613.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,206.25
|
| Rate for Payer: Multiplan Commercial |
$6,620.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,965.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,613.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,054.75
|
| Rate for Payer: Quartz Commercial |
$5,378.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,965.00
|
| Rate for Payer: The Alliance Commercial |
$33,100.00
|
| Rate for Payer: WEA Trust Commercial |
$4,551.25
|
| Rate for Payer: WPS Commercial |
$6,129.29
|
|
|
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 |
$4,054.75 |
| Max. Negotiated Rate |
$7,613.00 |
| Rate for Payer: Aetna Commercial |
$7,447.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,116.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,385.75
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,613.00
|
| Rate for Payer: Health EOS Commercial |
$7,364.75
|
| Rate for Payer: HFN Commercial |
$7,613.00
|
| Rate for Payer: Multiplan Commercial |
$6,620.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,965.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,613.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,054.75
|
| Rate for Payer: Quartz Commercial |
$4,965.00
|
| Rate for Payer: WEA Trust Commercial |
$4,551.25
|
| Rate for Payer: WPS Commercial |
$6,129.29
|
|
|
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 |
$2,317.00 |
| Max. Negotiated Rate |
$33,100.00 |
| Rate for Payer: Aetna Commercial |
$7,447.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,116.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,317.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,378.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,137.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,972.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,385.75
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,613.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,630.69
|
| Rate for Payer: Health EOS Commercial |
$7,364.75
|
| Rate for Payer: HFN Commercial |
$7,613.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,206.25
|
| Rate for Payer: Multiplan Commercial |
$6,620.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,965.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,613.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,054.75
|
| Rate for Payer: Quartz Commercial |
$5,378.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,965.00
|
| Rate for Payer: The Alliance Commercial |
$33,100.00
|
| Rate for Payer: WEA Trust Commercial |
$4,551.25
|
| Rate for Payer: WPS Commercial |
$6,129.29
|
|
|
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 |
$4,054.75 |
| Max. Negotiated Rate |
$7,613.00 |
| Rate for Payer: Aetna Commercial |
$7,447.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,116.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,385.75
|
| Rate for Payer: Cash Price |
$2,482.50
|
| Rate for Payer: Cigna Commercial |
$7,613.00
|
| Rate for Payer: Health EOS Commercial |
$7,364.75
|
| Rate for Payer: HFN Commercial |
$7,613.00
|
| Rate for Payer: Multiplan Commercial |
$6,620.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,965.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,613.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,054.75
|
| Rate for Payer: Quartz Commercial |
$4,965.00
|
| Rate for Payer: WEA Trust Commercial |
$4,551.25
|
| Rate for Payer: WPS Commercial |
$6,129.29
|
|
|
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 |
$2,351.51 |
| Max. Negotiated Rate |
$4,415.08 |
| Rate for Payer: Aetna Commercial |
$4,319.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,127.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,543.47
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,415.08
|
| Rate for Payer: Health EOS Commercial |
$4,271.11
|
| Rate for Payer: HFN Commercial |
$4,415.08
|
| Rate for Payer: Multiplan Commercial |
$3,839.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,879.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,415.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,351.51
|
| Rate for Payer: Quartz Commercial |
$2,879.40
|
| Rate for Payer: WEA Trust Commercial |
$2,639.45
|
| Rate for Payer: WPS Commercial |
$3,554.62
|
|
|
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 |
$1,343.72 |
| Max. Negotiated Rate |
$19,196.00 |
| Rate for Payer: Aetna Commercial |
$4,319.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,127.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,343.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,119.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,399.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,303.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,543.47
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,415.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,685.52
|
| Rate for Payer: Health EOS Commercial |
$4,271.11
|
| Rate for Payer: HFN Commercial |
$4,415.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,599.25
|
| Rate for Payer: Multiplan Commercial |
$3,839.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,879.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,415.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,351.51
|
| Rate for Payer: Quartz Commercial |
$3,119.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,879.40
|
| Rate for Payer: The Alliance Commercial |
$19,196.00
|
| Rate for Payer: WEA Trust Commercial |
$2,639.45
|
| Rate for Payer: WPS Commercial |
$3,554.62
|
|
|
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 |
$2,645.51 |
| Max. Negotiated Rate |
$4,967.08 |
| Rate for Payer: Aetna Commercial |
$4,859.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,643.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,861.47
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$4,967.08
|
| Rate for Payer: Health EOS Commercial |
$4,805.11
|
| Rate for Payer: HFN Commercial |
$4,967.08
|
| Rate for Payer: Multiplan Commercial |
$4,319.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,239.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,967.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,645.51
|
| Rate for Payer: Quartz Commercial |
$3,239.40
|
| Rate for Payer: WEA Trust Commercial |
$2,969.45
|
| Rate for Payer: WPS Commercial |
$3,999.04
|
|
|
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 |
$1,511.72 |
| Max. Negotiated Rate |
$21,596.00 |
| Rate for Payer: Aetna Commercial |
$4,859.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,643.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,511.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,509.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,699.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,591.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,861.47
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$4,967.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,021.28
|
| Rate for Payer: Health EOS Commercial |
$4,805.11
|
| Rate for Payer: HFN Commercial |
$4,967.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,049.25
|
| Rate for Payer: Multiplan Commercial |
$4,319.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,239.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,967.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,645.51
|
| Rate for Payer: Quartz Commercial |
$3,509.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,239.40
|
| Rate for Payer: The Alliance Commercial |
$21,596.00
|
| Rate for Payer: WEA Trust Commercial |
$2,969.45
|
| Rate for Payer: WPS Commercial |
$3,999.04
|
|
|
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 |
$1,453.48 |
| Max. Negotiated Rate |
$20,764.00 |
| Rate for Payer: Aetna Commercial |
$4,671.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,464.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,453.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,374.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,595.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,491.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,751.23
|
| Rate for Payer: Cash Price |
$1,557.30
|
| Rate for Payer: Cigna Commercial |
$4,775.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,904.88
|
| Rate for Payer: Health EOS Commercial |
$4,619.99
|
| Rate for Payer: HFN Commercial |
$4,775.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,893.25
|
| Rate for Payer: Multiplan Commercial |
$4,152.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,775.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,543.59
|
| Rate for Payer: Quartz Commercial |
$3,374.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3,114.60
|
| Rate for Payer: The Alliance Commercial |
$20,764.00
|
| Rate for Payer: WEA Trust Commercial |
$2,855.05
|
| Rate for Payer: WPS Commercial |
$3,844.97
|
|
|
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 |
$2,543.59 |
| Max. Negotiated Rate |
$4,775.72 |
| Rate for Payer: Aetna Commercial |
$4,671.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,464.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,751.23
|
| Rate for Payer: Cash Price |
$1,557.30
|
| Rate for Payer: Cigna Commercial |
$4,775.72
|
| Rate for Payer: Health EOS Commercial |
$4,619.99
|
| Rate for Payer: HFN Commercial |
$4,775.72
|
| Rate for Payer: Multiplan Commercial |
$4,152.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,775.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,543.59
|
| Rate for Payer: Quartz Commercial |
$3,114.60
|
| Rate for Payer: WEA Trust Commercial |
$2,855.05
|
| Rate for Payer: WPS Commercial |
$3,844.97
|
|
|
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 |
$2,645.51 |
| Max. Negotiated Rate |
$4,967.08 |
| Rate for Payer: Aetna Commercial |
$4,859.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,643.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,861.47
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$4,967.08
|
| Rate for Payer: Health EOS Commercial |
$4,805.11
|
| Rate for Payer: HFN Commercial |
$4,967.08
|
| Rate for Payer: Multiplan Commercial |
$4,319.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,239.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,967.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,645.51
|
| Rate for Payer: Quartz Commercial |
$3,239.40
|
| Rate for Payer: WEA Trust Commercial |
$2,969.45
|
| Rate for Payer: WPS Commercial |
$3,999.04
|
|
|
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 |
$1,511.72 |
| Max. Negotiated Rate |
$21,596.00 |
| Rate for Payer: Aetna Commercial |
$4,859.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,643.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,511.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,509.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,699.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,591.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,861.47
|
| Rate for Payer: Cash Price |
$1,619.70
|
| Rate for Payer: Cigna Commercial |
$4,967.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,021.28
|
| Rate for Payer: Health EOS Commercial |
$4,805.11
|
| Rate for Payer: HFN Commercial |
$4,967.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,049.25
|
| Rate for Payer: Multiplan Commercial |
$4,319.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,239.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,967.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,645.51
|
| Rate for Payer: Quartz Commercial |
$3,509.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,239.40
|
| Rate for Payer: The Alliance Commercial |
$21,596.00
|
| Rate for Payer: WEA Trust Commercial |
$2,969.45
|
| Rate for Payer: WPS Commercial |
$3,999.04
|
|
|
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 |
$2,351.51 |
| Max. Negotiated Rate |
$4,415.08 |
| Rate for Payer: Aetna Commercial |
$4,319.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,127.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,543.47
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,415.08
|
| Rate for Payer: Health EOS Commercial |
$4,271.11
|
| Rate for Payer: HFN Commercial |
$4,415.08
|
| Rate for Payer: Multiplan Commercial |
$3,839.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,879.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,415.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,351.51
|
| Rate for Payer: Quartz Commercial |
$2,879.40
|
| Rate for Payer: WEA Trust Commercial |
$2,639.45
|
| Rate for Payer: WPS Commercial |
$3,554.62
|
|
|
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 |
$1,343.72 |
| Max. Negotiated Rate |
$19,196.00 |
| Rate for Payer: Aetna Commercial |
$4,319.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,127.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,343.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,119.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,399.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,303.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,543.47
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,415.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,685.52
|
| Rate for Payer: Health EOS Commercial |
$4,271.11
|
| Rate for Payer: HFN Commercial |
$4,415.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,599.25
|
| Rate for Payer: Multiplan Commercial |
$3,839.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,879.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,415.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,351.51
|
| Rate for Payer: Quartz Commercial |
$3,119.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,879.40
|
| Rate for Payer: The Alliance Commercial |
$19,196.00
|
| Rate for Payer: WEA Trust Commercial |
$2,639.45
|
| Rate for Payer: WPS Commercial |
$3,554.62
|
|
|
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 |
$2,351.51 |
| Max. Negotiated Rate |
$4,415.08 |
| Rate for Payer: Aetna Commercial |
$4,319.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,127.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,543.47
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,415.08
|
| Rate for Payer: Health EOS Commercial |
$4,271.11
|
| Rate for Payer: HFN Commercial |
$4,415.08
|
| Rate for Payer: Multiplan Commercial |
$3,839.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,879.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,415.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,351.51
|
| Rate for Payer: Quartz Commercial |
$2,879.40
|
| Rate for Payer: WEA Trust Commercial |
$2,639.45
|
| Rate for Payer: WPS Commercial |
$3,554.62
|
|
|
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 |
$1,343.72 |
| Max. Negotiated Rate |
$19,196.00 |
| Rate for Payer: Aetna Commercial |
$4,319.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,127.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,343.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,119.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,399.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,303.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,543.47
|
| Rate for Payer: Cash Price |
$1,439.70
|
| Rate for Payer: Cigna Commercial |
$4,415.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,685.52
|
| Rate for Payer: Health EOS Commercial |
$4,271.11
|
| Rate for Payer: HFN Commercial |
$4,415.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,599.25
|
| Rate for Payer: Multiplan Commercial |
$3,839.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,879.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,415.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,351.51
|
| Rate for Payer: Quartz Commercial |
$3,119.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,879.40
|
| Rate for Payer: The Alliance Commercial |
$19,196.00
|
| Rate for Payer: WEA Trust Commercial |
$2,639.45
|
| Rate for Payer: WPS Commercial |
$3,554.62
|
|
