|
PATCH IONTO #199589-001***OBSOLETE FROM DJO
|
Facility
|
IP
|
$197.00
|
|
| Hospital Charge Code |
2969754
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.53 |
| Max. Negotiated Rate |
$181.24 |
| Rate for Payer: Aetna Commercial |
$177.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.41
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$181.24
|
| Rate for Payer: Health EOS Commercial |
$175.33
|
| Rate for Payer: HFN Commercial |
$181.24
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: NAPHCARE Commercial |
$118.20
|
| Rate for Payer: Preferred Network Access Commercial |
$181.24
|
| Rate for Payer: Quartz Beloit One Network |
$96.53
|
| Rate for Payer: Quartz Commercial |
$118.20
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
PATCH VASCU-GUARD PERIPHERAL VASCULAR BOVINE VG-0108N/VG-0108
|
Facility
|
IP
|
$2,488.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3707495
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,219.12 |
| Max. Negotiated Rate |
$2,288.96 |
| Rate for Payer: Aetna Commercial |
$2,239.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,139.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,318.64
|
| Rate for Payer: Cash Price |
$746.40
|
| Rate for Payer: Cigna Commercial |
$2,288.96
|
| Rate for Payer: Health EOS Commercial |
$2,214.32
|
| Rate for Payer: HFN Commercial |
$2,288.96
|
| Rate for Payer: Multiplan Commercial |
$1,990.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,492.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,288.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,219.12
|
| Rate for Payer: Quartz Commercial |
$1,492.80
|
| Rate for Payer: WEA Trust Commercial |
$1,368.40
|
| Rate for Payer: WPS Commercial |
$1,842.86
|
|
|
PATCH VASCU-GUARD PERIPHERAL VASCULAR BOVINE VG-0108N/VG-0108
|
Facility
|
OP
|
$2,488.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
3707495
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$696.64 |
| Max. Negotiated Rate |
$9,952.00 |
| Rate for Payer: Aetna Commercial |
$2,239.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,139.68
|
| Rate for Payer: Aetna Managed Medicare |
$696.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,617.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,244.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,194.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,318.64
|
| Rate for Payer: Cash Price |
$746.40
|
| Rate for Payer: Cigna Commercial |
$2,288.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,392.28
|
| Rate for Payer: Health EOS Commercial |
$2,214.32
|
| Rate for Payer: HFN Commercial |
$2,288.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,866.00
|
| Rate for Payer: Multiplan Commercial |
$1,990.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,492.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,288.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,219.12
|
| Rate for Payer: Quartz Commercial |
$1,617.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,492.80
|
| Rate for Payer: The Alliance Commercial |
$9,952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,368.40
|
| Rate for Payer: WPS Commercial |
$1,842.86
|
|
|
PATCH XENOSURE BOVINE 0.8CMX8CM 0.8P8
|
Facility
|
IP
|
$2,536.00
|
|
| Hospital Charge Code |
4519241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,242.64 |
| Max. Negotiated Rate |
$2,333.12 |
| Rate for Payer: Aetna Commercial |
$2,282.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,180.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.08
|
| Rate for Payer: Cash Price |
$760.80
|
| Rate for Payer: Cigna Commercial |
$2,333.12
|
| Rate for Payer: Health EOS Commercial |
$2,257.04
|
| Rate for Payer: HFN Commercial |
$2,333.12
|
| Rate for Payer: Multiplan Commercial |
$2,028.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,521.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,333.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,242.64
|
| Rate for Payer: Quartz Commercial |
$1,521.60
|
| Rate for Payer: WEA Trust Commercial |
$1,394.80
|
| Rate for Payer: WPS Commercial |
$1,878.42
|
|
|
PATCH XENOSURE BOVINE 0.8CMX8CM 0.8P8
|
Facility
|
OP
|
$2,536.00
|
|
| Hospital Charge Code |
4519241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.08 |
| Max. Negotiated Rate |
$10,144.00 |
| Rate for Payer: Aetna Commercial |
$2,282.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,180.96
|
| Rate for Payer: Aetna Managed Medicare |
$710.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,648.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,268.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,217.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.08
|
| Rate for Payer: Cash Price |
$760.80
|
| Rate for Payer: Cigna Commercial |
$2,333.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,419.15
|
| Rate for Payer: Health EOS Commercial |
$2,257.04
|
| Rate for Payer: HFN Commercial |
$2,333.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,902.00
|
| Rate for Payer: Multiplan Commercial |
$2,028.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,521.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,333.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,242.64
|
| Rate for Payer: Quartz Commercial |
$1,648.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,521.60
|
| Rate for Payer: The Alliance Commercial |
$10,144.00
|
| Rate for Payer: WEA Trust Commercial |
$1,394.80
|
| Rate for Payer: WPS Commercial |
$1,878.42
|
|
|
PATELLA 26MM PROLONG 00-5972-066-26
|
Facility
|
OP
|
$7,229.00
|
|
| Hospital Charge Code |
2967764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.12 |
| Max. Negotiated Rate |
$28,916.00 |
| Rate for Payer: Aetna Commercial |
$6,506.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,216.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,024.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,698.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,614.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,469.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,831.37
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,650.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,045.35
|
| Rate for Payer: Health EOS Commercial |
$6,433.81
|
| Rate for Payer: HFN Commercial |
$6,650.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,421.75
|
| Rate for Payer: Multiplan Commercial |
$5,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,337.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,650.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,542.21
|
| Rate for Payer: Quartz Commercial |
$4,698.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,337.40
|
| Rate for Payer: The Alliance Commercial |
$28,916.00
|
| Rate for Payer: WEA Trust Commercial |
$3,975.95
|
| Rate for Payer: WPS Commercial |
$5,354.52
|
|
|
PATELLA 26MM PROLONG 00-5972-066-26
|
Facility
|
IP
|
$7,229.00
|
|
| Hospital Charge Code |
2967764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,542.21 |
| Max. Negotiated Rate |
$6,650.68 |
| Rate for Payer: Aetna Commercial |
$6,506.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,216.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,831.37
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,650.68
|
| Rate for Payer: Health EOS Commercial |
$6,433.81
|
| Rate for Payer: HFN Commercial |
$6,650.68
|
| Rate for Payer: Multiplan Commercial |
$5,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,337.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,650.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,542.21
|
| Rate for Payer: Quartz Commercial |
$4,337.40
|
| Rate for Payer: WEA Trust Commercial |
$3,975.95
|
| Rate for Payer: WPS Commercial |
$5,354.52
|
|
|
PATELLA 29MM PROLONG 00-5972-066-29
|
Facility
|
OP
|
$7,229.00
|
|
| Hospital Charge Code |
2967765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.12 |
| Max. Negotiated Rate |
$28,916.00 |
| Rate for Payer: Aetna Commercial |
$6,506.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,216.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,024.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,698.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,614.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,469.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,831.37
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,650.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,045.35
|
| Rate for Payer: Health EOS Commercial |
$6,433.81
|
| Rate for Payer: HFN Commercial |
$6,650.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,421.75
|
| Rate for Payer: Multiplan Commercial |
$5,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,337.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,650.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,542.21
|
| Rate for Payer: Quartz Commercial |
$4,698.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,337.40
|
| Rate for Payer: The Alliance Commercial |
$28,916.00
|
| Rate for Payer: WEA Trust Commercial |
$3,975.95
|
| Rate for Payer: WPS Commercial |
$5,354.52
|
|
|
PATELLA 29MM PROLONG 00-5972-066-29
|
Facility
|
IP
|
$7,229.00
|
|
| Hospital Charge Code |
2967765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,542.21 |
| Max. Negotiated Rate |
$6,650.68 |
| Rate for Payer: Aetna Commercial |
$6,506.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,216.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,831.37
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,650.68
|
| Rate for Payer: Health EOS Commercial |
$6,433.81
|
| Rate for Payer: HFN Commercial |
$6,650.68
|
| Rate for Payer: Multiplan Commercial |
$5,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,337.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,650.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,542.21
|
| Rate for Payer: Quartz Commercial |
$4,337.40
|
| Rate for Payer: WEA Trust Commercial |
$3,975.95
|
| Rate for Payer: WPS Commercial |
$5,354.52
|
|
|
PATELLA 32MM PROLONG 00-5972-066-32
|
Facility
|
OP
|
$7,508.00
|
|
| Hospital Charge Code |
2967766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,102.24 |
| Max. Negotiated Rate |
$30,032.00 |
| Rate for Payer: Aetna Commercial |
$6,757.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,456.88
|
| Rate for Payer: Aetna Managed Medicare |
$2,102.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,880.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,754.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,603.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,979.24
|
| Rate for Payer: Cash Price |
$2,252.40
|
| Rate for Payer: Cigna Commercial |
$6,907.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,201.48
|
| Rate for Payer: Health EOS Commercial |
$6,682.12
|
| Rate for Payer: HFN Commercial |
$6,907.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,631.00
|
| Rate for Payer: Multiplan Commercial |
$6,006.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,504.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,907.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,678.92
|
| Rate for Payer: Quartz Commercial |
$4,880.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,504.80
|
| Rate for Payer: The Alliance Commercial |
$30,032.00
|
| Rate for Payer: WEA Trust Commercial |
$4,129.40
|
| Rate for Payer: WPS Commercial |
$5,561.18
|
|
|
PATELLA 32MM PROLONG 00-5972-066-32
|
Facility
|
IP
|
$7,508.00
|
|
| Hospital Charge Code |
2967766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,678.92 |
| Max. Negotiated Rate |
$6,907.36 |
| Rate for Payer: Aetna Commercial |
$6,757.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,456.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,979.24
|
| Rate for Payer: Cash Price |
$2,252.40
|
| Rate for Payer: Cigna Commercial |
$6,907.36
|
| Rate for Payer: Health EOS Commercial |
$6,682.12
|
| Rate for Payer: HFN Commercial |
$6,907.36
|
| Rate for Payer: Multiplan Commercial |
$6,006.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,504.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,907.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,678.92
|
| Rate for Payer: Quartz Commercial |
$4,504.80
|
| Rate for Payer: WEA Trust Commercial |
$4,129.40
|
| Rate for Payer: WPS Commercial |
$5,561.18
|
|
|
PATELLA 35MM PROLONG 00-5972-066-35
|
Facility
|
IP
|
$7,508.00
|
|
| Hospital Charge Code |
2967767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,678.92 |
| Max. Negotiated Rate |
$6,907.36 |
| Rate for Payer: Aetna Commercial |
$6,757.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,456.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,979.24
|
| Rate for Payer: Cash Price |
$2,252.40
|
| Rate for Payer: Cigna Commercial |
$6,907.36
|
| Rate for Payer: Health EOS Commercial |
$6,682.12
|
| Rate for Payer: HFN Commercial |
$6,907.36
|
| Rate for Payer: Multiplan Commercial |
$6,006.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,504.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,907.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,678.92
|
| Rate for Payer: Quartz Commercial |
$4,504.80
|
| Rate for Payer: WEA Trust Commercial |
$4,129.40
|
| Rate for Payer: WPS Commercial |
$5,561.18
|
|
|
PATELLA 35MM PROLONG 00-5972-066-35
|
Facility
|
OP
|
$7,508.00
|
|
| Hospital Charge Code |
2967767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,102.24 |
| Max. Negotiated Rate |
$30,032.00 |
| Rate for Payer: Aetna Commercial |
$6,757.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,456.88
|
| Rate for Payer: Aetna Managed Medicare |
$2,102.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,880.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,754.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,603.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,979.24
|
| Rate for Payer: Cash Price |
$2,252.40
|
| Rate for Payer: Cigna Commercial |
$6,907.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,201.48
|
| Rate for Payer: Health EOS Commercial |
$6,682.12
|
| Rate for Payer: HFN Commercial |
$6,907.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,631.00
|
| Rate for Payer: Multiplan Commercial |
$6,006.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,504.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,907.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,678.92
|
| Rate for Payer: Quartz Commercial |
$4,880.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,504.80
|
| Rate for Payer: The Alliance Commercial |
$30,032.00
|
| Rate for Payer: WEA Trust Commercial |
$4,129.40
|
| Rate for Payer: WPS Commercial |
$5,561.18
|
|
|
PATELLA 38MM PROLONG 00-5972-066-38
|
Facility
|
OP
|
$7,229.00
|
|
| Hospital Charge Code |
2967768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.12 |
| Max. Negotiated Rate |
$28,916.00 |
| Rate for Payer: Aetna Commercial |
$6,506.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,216.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,024.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,698.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,614.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,469.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,831.37
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,650.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,045.35
|
| Rate for Payer: Health EOS Commercial |
$6,433.81
|
| Rate for Payer: HFN Commercial |
$6,650.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,421.75
|
| Rate for Payer: Multiplan Commercial |
$5,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,337.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,650.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,542.21
|
| Rate for Payer: Quartz Commercial |
$4,698.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,337.40
|
| Rate for Payer: The Alliance Commercial |
$28,916.00
|
| Rate for Payer: WEA Trust Commercial |
$3,975.95
|
| Rate for Payer: WPS Commercial |
$5,354.52
|
|
|
PATELLA 38MM PROLONG 00-5972-066-38
|
Facility
|
IP
|
$7,229.00
|
|
| Hospital Charge Code |
2967768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,542.21 |
| Max. Negotiated Rate |
$6,650.68 |
| Rate for Payer: Aetna Commercial |
$6,506.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,216.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,831.37
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,650.68
|
| Rate for Payer: Health EOS Commercial |
$6,433.81
|
| Rate for Payer: HFN Commercial |
$6,650.68
|
| Rate for Payer: Multiplan Commercial |
$5,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,337.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,650.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,542.21
|
| Rate for Payer: Quartz Commercial |
$4,337.40
|
| Rate for Payer: WEA Trust Commercial |
$3,975.95
|
| Rate for Payer: WPS Commercial |
$5,354.52
|
|
|
PATELLA 3-PEG P3 NX043
|
Facility
|
OP
|
$4,918.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,377.04 |
| Max. Negotiated Rate |
$19,672.00 |
| Rate for Payer: Aetna Commercial |
$4,426.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,229.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,377.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,196.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,459.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,360.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,606.54
|
| Rate for Payer: Cash Price |
$1,475.40
|
| Rate for Payer: Cigna Commercial |
$4,524.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,752.11
|
| Rate for Payer: Health EOS Commercial |
$4,377.02
|
| Rate for Payer: HFN Commercial |
$4,524.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,688.50
|
| Rate for Payer: Multiplan Commercial |
$3,934.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,950.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,524.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,409.82
|
| Rate for Payer: Quartz Commercial |
$3,196.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,950.80
|
| Rate for Payer: The Alliance Commercial |
$19,672.00
|
| Rate for Payer: WEA Trust Commercial |
$2,704.90
|
| Rate for Payer: WPS Commercial |
$3,642.76
|
|
|
PATELLA 3-PEG P3 NX043
|
Facility
|
IP
|
$4,918.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,409.82 |
| Max. Negotiated Rate |
$4,524.56 |
| Rate for Payer: Aetna Commercial |
$4,426.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,229.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,606.54
|
| Rate for Payer: Cash Price |
$1,475.40
|
| Rate for Payer: Cigna Commercial |
$4,524.56
|
| Rate for Payer: Health EOS Commercial |
$4,377.02
|
| Rate for Payer: HFN Commercial |
$4,524.56
|
| Rate for Payer: Multiplan Commercial |
$3,934.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,950.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,524.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,409.82
|
| Rate for Payer: Quartz Commercial |
$2,950.80
|
| Rate for Payer: WEA Trust Commercial |
$2,704.90
|
| Rate for Payer: WPS Commercial |
$3,642.76
|
|
|
PATELLA 41MM PROLONG 00-5972-066-41
|
Facility
|
OP
|
$7,229.00
|
|
| Hospital Charge Code |
2967769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.12 |
| Max. Negotiated Rate |
$28,916.00 |
| Rate for Payer: Aetna Commercial |
$6,506.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,216.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,024.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,698.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,614.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,469.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,831.37
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,650.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,045.35
|
| Rate for Payer: Health EOS Commercial |
$6,433.81
|
| Rate for Payer: HFN Commercial |
$6,650.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,421.75
|
| Rate for Payer: Multiplan Commercial |
$5,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,337.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,650.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,542.21
|
| Rate for Payer: Quartz Commercial |
$4,698.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,337.40
|
| Rate for Payer: The Alliance Commercial |
$28,916.00
|
| Rate for Payer: WEA Trust Commercial |
$3,975.95
|
| Rate for Payer: WPS Commercial |
$5,354.52
|
|
|
PATELLA 41MM PROLONG 00-5972-066-41
|
Facility
|
IP
|
$7,229.00
|
|
| Hospital Charge Code |
2967769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,542.21 |
| Max. Negotiated Rate |
$6,650.68 |
| Rate for Payer: Aetna Commercial |
$6,506.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,216.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,831.37
|
| Rate for Payer: Cash Price |
$2,168.70
|
| Rate for Payer: Cigna Commercial |
$6,650.68
|
| Rate for Payer: Health EOS Commercial |
$6,433.81
|
| Rate for Payer: HFN Commercial |
$6,650.68
|
| Rate for Payer: Multiplan Commercial |
$5,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,337.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,650.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,542.21
|
| Rate for Payer: Quartz Commercial |
$4,337.40
|
| Rate for Payer: WEA Trust Commercial |
$3,975.95
|
| Rate for Payer: WPS Commercial |
$5,354.52
|
|
|
PATELLA ATTUNE MEDIALIZED ANATOMIC 29MM CEMENTED 1518-10-029
|
Facility
|
OP
|
$4,610.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5611655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,290.80 |
| Max. Negotiated Rate |
$18,440.00 |
| Rate for Payer: Aetna Commercial |
$4,149.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,964.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,290.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,996.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,305.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,212.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,443.30
|
| Rate for Payer: Cash Price |
$1,383.00
|
| Rate for Payer: Cigna Commercial |
$4,241.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,579.76
|
| Rate for Payer: Health EOS Commercial |
$4,102.90
|
| Rate for Payer: HFN Commercial |
$4,241.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,457.50
|
| Rate for Payer: Multiplan Commercial |
$3,688.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,766.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,241.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,258.90
|
| Rate for Payer: Quartz Commercial |
$2,996.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,766.00
|
| Rate for Payer: The Alliance Commercial |
$18,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,535.50
|
| Rate for Payer: WPS Commercial |
$3,414.63
|
|
|
PATELLA ATTUNE MEDIALIZED ANATOMIC 29MM CEMENTED 1518-10-029
|
Facility
|
IP
|
$4,610.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5611655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,258.90 |
| Max. Negotiated Rate |
$4,241.20 |
| Rate for Payer: Aetna Commercial |
$4,149.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,964.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,443.30
|
| Rate for Payer: Cash Price |
$1,383.00
|
| Rate for Payer: Cigna Commercial |
$4,241.20
|
| Rate for Payer: Health EOS Commercial |
$4,102.90
|
| Rate for Payer: HFN Commercial |
$4,241.20
|
| Rate for Payer: Multiplan Commercial |
$3,688.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,766.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,241.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,258.90
|
| Rate for Payer: Quartz Commercial |
$2,766.00
|
| Rate for Payer: WEA Trust Commercial |
$2,535.50
|
| Rate for Payer: WPS Commercial |
$3,414.63
|
|
|
PATELLA ATTUNE MEDIALIZED ANATOMIC 32MM CEMENTED 1518-10-032
|
Facility
|
OP
|
$6,319.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459755
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,769.32 |
| Max. Negotiated Rate |
$25,276.00 |
| Rate for Payer: Aetna Commercial |
$5,687.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,434.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,769.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,107.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,159.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,033.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,349.07
|
| Rate for Payer: Cash Price |
$1,895.70
|
| Rate for Payer: Cigna Commercial |
$5,813.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,536.11
|
| Rate for Payer: Health EOS Commercial |
$5,623.91
|
| Rate for Payer: HFN Commercial |
$5,813.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,739.25
|
| Rate for Payer: Multiplan Commercial |
$5,055.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,791.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,813.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,096.31
|
| Rate for Payer: Quartz Commercial |
$4,107.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,791.40
|
| Rate for Payer: The Alliance Commercial |
$25,276.00
|
| Rate for Payer: WEA Trust Commercial |
$3,475.45
|
| Rate for Payer: WPS Commercial |
$4,680.48
|
|
|
PATELLA ATTUNE MEDIALIZED ANATOMIC 32MM CEMENTED 1518-10-032
|
Facility
|
IP
|
$6,319.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459755
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,096.31 |
| Max. Negotiated Rate |
$5,813.48 |
| Rate for Payer: Aetna Commercial |
$5,687.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,434.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,349.07
|
| Rate for Payer: Cash Price |
$1,895.70
|
| Rate for Payer: Cigna Commercial |
$5,813.48
|
| Rate for Payer: Health EOS Commercial |
$5,623.91
|
| Rate for Payer: HFN Commercial |
$5,813.48
|
| Rate for Payer: Multiplan Commercial |
$5,055.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,791.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,813.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,096.31
|
| Rate for Payer: Quartz Commercial |
$3,791.40
|
| Rate for Payer: WEA Trust Commercial |
$3,475.45
|
| Rate for Payer: WPS Commercial |
$4,680.48
|
|
|
PATELLA ATTUNE MEDIALIZED ANATOMIC 35MM CEMENTED 1518-10-035
|
Facility
|
IP
|
$6,319.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,096.31 |
| Max. Negotiated Rate |
$5,813.48 |
| Rate for Payer: Aetna Commercial |
$5,687.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,434.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,349.07
|
| Rate for Payer: Cash Price |
$1,895.70
|
| Rate for Payer: Cigna Commercial |
$5,813.48
|
| Rate for Payer: Health EOS Commercial |
$5,623.91
|
| Rate for Payer: HFN Commercial |
$5,813.48
|
| Rate for Payer: Multiplan Commercial |
$5,055.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,791.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,813.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,096.31
|
| Rate for Payer: Quartz Commercial |
$3,791.40
|
| Rate for Payer: WEA Trust Commercial |
$3,475.45
|
| Rate for Payer: WPS Commercial |
$4,680.48
|
|
|
PATELLA ATTUNE MEDIALIZED ANATOMIC 35MM CEMENTED 1518-10-035
|
Facility
|
OP
|
$6,319.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,769.32 |
| Max. Negotiated Rate |
$25,276.00 |
| Rate for Payer: Aetna Commercial |
$5,687.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,434.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,769.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,107.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,159.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,033.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,349.07
|
| Rate for Payer: Cash Price |
$1,895.70
|
| Rate for Payer: Cigna Commercial |
$5,813.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,536.11
|
| Rate for Payer: Health EOS Commercial |
$5,623.91
|
| Rate for Payer: HFN Commercial |
$5,813.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,739.25
|
| Rate for Payer: Multiplan Commercial |
$5,055.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,791.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,813.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,096.31
|
| Rate for Payer: Quartz Commercial |
$4,107.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,791.40
|
| Rate for Payer: The Alliance Commercial |
$25,276.00
|
| Rate for Payer: WEA Trust Commercial |
$3,475.45
|
| Rate for Payer: WPS Commercial |
$4,680.48
|
|
