|
PATELLA PERSONA VE 32MM 42-5402-000-32
|
Facility
|
IP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177471
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,398.15 |
| Max. Negotiated Rate |
$6,380.20 |
| Rate for Payer: Aetna Commercial |
$6,241.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,964.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,675.55
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,380.20
|
| Rate for Payer: Health EOS Commercial |
$6,172.15
|
| Rate for Payer: HFN Commercial |
$6,380.20
|
| Rate for Payer: Multiplan Commercial |
$5,548.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,161.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,380.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,398.15
|
| Rate for Payer: Quartz Commercial |
$4,161.00
|
| Rate for Payer: WEA Trust Commercial |
$3,814.25
|
| Rate for Payer: WPS Commercial |
$5,136.75
|
|
|
PATELLA PERSONA VE 35MM 42-5402-000-35
|
Facility
|
IP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,398.15 |
| Max. Negotiated Rate |
$6,380.20 |
| Rate for Payer: Aetna Commercial |
$6,241.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,964.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,675.55
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,380.20
|
| Rate for Payer: Health EOS Commercial |
$6,172.15
|
| Rate for Payer: HFN Commercial |
$6,380.20
|
| Rate for Payer: Multiplan Commercial |
$5,548.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,161.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,380.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,398.15
|
| Rate for Payer: Quartz Commercial |
$4,161.00
|
| Rate for Payer: WEA Trust Commercial |
$3,814.25
|
| Rate for Payer: WPS Commercial |
$5,136.75
|
|
|
PATELLA PERSONA VE 35MM 42-5402-000-35
|
Facility
|
OP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,941.80 |
| Max. Negotiated Rate |
$27,740.00 |
| Rate for Payer: Aetna Commercial |
$6,241.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,964.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,941.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,507.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,467.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,328.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,675.55
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,380.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,880.83
|
| Rate for Payer: Health EOS Commercial |
$6,172.15
|
| Rate for Payer: HFN Commercial |
$6,380.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,201.25
|
| Rate for Payer: Multiplan Commercial |
$5,548.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,161.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,380.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,398.15
|
| Rate for Payer: Quartz Commercial |
$4,507.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,161.00
|
| Rate for Payer: The Alliance Commercial |
$27,740.00
|
| Rate for Payer: WEA Trust Commercial |
$3,814.25
|
| Rate for Payer: WPS Commercial |
$5,136.75
|
|
|
PATELLA PERSONA VE 38MM 42-5402-000-38
|
Facility
|
IP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3727504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,398.15 |
| Max. Negotiated Rate |
$6,380.20 |
| Rate for Payer: Aetna Commercial |
$6,241.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,964.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,675.55
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,380.20
|
| Rate for Payer: Health EOS Commercial |
$6,172.15
|
| Rate for Payer: HFN Commercial |
$6,380.20
|
| Rate for Payer: Multiplan Commercial |
$5,548.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,161.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,380.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,398.15
|
| Rate for Payer: Quartz Commercial |
$4,161.00
|
| Rate for Payer: WEA Trust Commercial |
$3,814.25
|
| Rate for Payer: WPS Commercial |
$5,136.75
|
|
|
PATELLA PERSONA VE 38MM 42-5402-000-38
|
Facility
|
OP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3727504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,941.80 |
| Max. Negotiated Rate |
$27,740.00 |
| Rate for Payer: Aetna Commercial |
$6,241.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,964.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,941.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,507.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,467.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,328.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,675.55
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,380.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,880.83
|
| Rate for Payer: Health EOS Commercial |
$6,172.15
|
| Rate for Payer: HFN Commercial |
$6,380.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,201.25
|
| Rate for Payer: Multiplan Commercial |
$5,548.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,161.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,380.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,398.15
|
| Rate for Payer: Quartz Commercial |
$4,507.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,161.00
|
| Rate for Payer: The Alliance Commercial |
$27,740.00
|
| Rate for Payer: WEA Trust Commercial |
$3,814.25
|
| Rate for Payer: WPS Commercial |
$5,136.75
|
|
|
PATELLA PERSONA VE 41MM 42-5402-000-41
|
Facility
|
OP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3697515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,941.80 |
| Max. Negotiated Rate |
$27,740.00 |
| Rate for Payer: Aetna Commercial |
$6,241.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,964.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,941.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,507.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,467.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,328.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,675.55
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,380.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,880.83
|
| Rate for Payer: Health EOS Commercial |
$6,172.15
|
| Rate for Payer: HFN Commercial |
$6,380.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,201.25
|
| Rate for Payer: Multiplan Commercial |
$5,548.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,161.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,380.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,398.15
|
| Rate for Payer: Quartz Commercial |
$4,507.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,161.00
|
| Rate for Payer: The Alliance Commercial |
$27,740.00
|
| Rate for Payer: WEA Trust Commercial |
$3,814.25
|
| Rate for Payer: WPS Commercial |
$5,136.75
|
|
|
PATELLA PERSONA VE 41MM 42-5402-000-41
|
Facility
|
IP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3697515
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,398.15 |
| Max. Negotiated Rate |
$6,380.20 |
| Rate for Payer: Aetna Commercial |
$6,241.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,964.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,675.55
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,380.20
|
| Rate for Payer: Health EOS Commercial |
$6,172.15
|
| Rate for Payer: HFN Commercial |
$6,380.20
|
| Rate for Payer: Multiplan Commercial |
$5,548.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,161.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,380.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,398.15
|
| Rate for Payer: Quartz Commercial |
$4,161.00
|
| Rate for Payer: WEA Trust Commercial |
$3,814.25
|
| Rate for Payer: WPS Commercial |
$5,136.75
|
|
|
PATELLAR COMPONENT 32mm 71420576
|
Facility
|
OP
|
$6,772.00
|
|
| Hospital Charge Code |
2966029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,896.16 |
| Max. Negotiated Rate |
$27,088.00 |
| Rate for Payer: Aetna Commercial |
$6,094.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,823.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,896.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,401.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,386.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,250.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,589.16
|
| Rate for Payer: Cash Price |
$2,031.60
|
| Rate for Payer: Cigna Commercial |
$6,230.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,789.61
|
| Rate for Payer: Health EOS Commercial |
$6,027.08
|
| Rate for Payer: HFN Commercial |
$6,230.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,079.00
|
| Rate for Payer: Multiplan Commercial |
$5,417.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,063.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,230.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,318.28
|
| Rate for Payer: Quartz Commercial |
$4,401.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,063.20
|
| Rate for Payer: The Alliance Commercial |
$27,088.00
|
| Rate for Payer: WEA Trust Commercial |
$3,724.60
|
| Rate for Payer: WPS Commercial |
$5,016.02
|
|
|
PATELLAR COMPONENT 32mm 71420576
|
Facility
|
IP
|
$6,772.00
|
|
| Hospital Charge Code |
2966029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,318.28 |
| Max. Negotiated Rate |
$6,230.24 |
| Rate for Payer: Aetna Commercial |
$6,094.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,823.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,589.16
|
| Rate for Payer: Cash Price |
$2,031.60
|
| Rate for Payer: Cigna Commercial |
$6,230.24
|
| Rate for Payer: Health EOS Commercial |
$6,027.08
|
| Rate for Payer: HFN Commercial |
$6,230.24
|
| Rate for Payer: Multiplan Commercial |
$5,417.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,063.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,230.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,318.28
|
| Rate for Payer: Quartz Commercial |
$4,063.20
|
| Rate for Payer: WEA Trust Commercial |
$3,724.60
|
| Rate for Payer: WPS Commercial |
$5,016.02
|
|
|
PATELLA ROUND DOME 35MM 96-0111
|
Facility
|
OP
|
$4,219.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,181.32 |
| Max. Negotiated Rate |
$16,876.00 |
| Rate for Payer: Aetna Commercial |
$3,797.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,628.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,181.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,742.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,109.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,025.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,236.07
|
| Rate for Payer: Cash Price |
$1,265.70
|
| Rate for Payer: Cigna Commercial |
$3,881.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,360.95
|
| Rate for Payer: Health EOS Commercial |
$3,754.91
|
| Rate for Payer: HFN Commercial |
$3,881.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,164.25
|
| Rate for Payer: Multiplan Commercial |
$3,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,531.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,881.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,067.31
|
| Rate for Payer: Quartz Commercial |
$2,742.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,531.40
|
| Rate for Payer: The Alliance Commercial |
$16,876.00
|
| Rate for Payer: WEA Trust Commercial |
$2,320.45
|
| Rate for Payer: WPS Commercial |
$3,125.01
|
|
|
PATELLA ROUND DOME 35MM 96-0111
|
Facility
|
IP
|
$4,219.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,067.31 |
| Max. Negotiated Rate |
$3,881.48 |
| Rate for Payer: Aetna Commercial |
$3,797.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,628.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,236.07
|
| Rate for Payer: Cash Price |
$1,265.70
|
| Rate for Payer: Cigna Commercial |
$3,881.48
|
| Rate for Payer: Health EOS Commercial |
$3,754.91
|
| Rate for Payer: HFN Commercial |
$3,881.48
|
| Rate for Payer: Multiplan Commercial |
$3,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,531.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,881.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,067.31
|
| Rate for Payer: Quartz Commercial |
$2,531.40
|
| Rate for Payer: WEA Trust Commercial |
$2,320.45
|
| Rate for Payer: WPS Commercial |
$3,125.01
|
|
|
PATELLA TENDON REPAIR, RUPTURED
|
Facility
|
OP
|
$4,912.00
|
|
| Hospital Charge Code |
2960535
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,375.36 |
| Max. Negotiated Rate |
$19,648.00 |
| Rate for Payer: Aetna Commercial |
$4,420.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,224.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,375.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,192.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,456.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,357.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,603.36
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,519.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,748.76
|
| Rate for Payer: Health EOS Commercial |
$4,371.68
|
| Rate for Payer: HFN Commercial |
$4,519.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,684.00
|
| Rate for Payer: Multiplan Commercial |
$3,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,519.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,406.88
|
| Rate for Payer: Quartz Commercial |
$3,192.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,947.20
|
| Rate for Payer: The Alliance Commercial |
$19,648.00
|
| Rate for Payer: WEA Trust Commercial |
$2,701.60
|
| Rate for Payer: WPS Commercial |
$3,638.32
|
|
|
PATELLA TENDON REPAIR, RUPTURED
|
Facility
|
IP
|
$4,912.00
|
|
| Hospital Charge Code |
2960535
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,406.88 |
| Max. Negotiated Rate |
$4,519.04 |
| Rate for Payer: Aetna Commercial |
$4,420.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,224.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,603.36
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,519.04
|
| Rate for Payer: Health EOS Commercial |
$4,371.68
|
| Rate for Payer: HFN Commercial |
$4,519.04
|
| Rate for Payer: Multiplan Commercial |
$3,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,519.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,406.88
|
| Rate for Payer: Quartz Commercial |
$2,947.20
|
| Rate for Payer: WEA Trust Commercial |
$2,701.60
|
| Rate for Payer: WPS Commercial |
$3,638.32
|
|
|
PATELLA TRIATHLON A29 5551-G-299
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
3072400
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,689.12 |
| Max. Negotiated Rate |
$5,048.96 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,292.80
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON A29 5551-G-299
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
3072400
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,536.64 |
| Max. Negotiated Rate |
$21,952.00 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,536.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,567.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,744.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,634.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,071.08
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,116.00
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,567.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,292.80
|
| Rate for Payer: The Alliance Commercial |
$21,952.00
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON A32 5551-G-320
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
3177479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,536.64 |
| Max. Negotiated Rate |
$21,952.00 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,536.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,567.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,744.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,634.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,071.08
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,116.00
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,567.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,292.80
|
| Rate for Payer: The Alliance Commercial |
$21,952.00
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON A32 5551-G-320
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
3177479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,689.12 |
| Max. Negotiated Rate |
$5,048.96 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,292.80
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON A35 5551-G-350
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
3127477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,689.12 |
| Max. Negotiated Rate |
$5,048.96 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,292.80
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON A35 5551-G-350
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
3127477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,536.64 |
| Max. Negotiated Rate |
$21,952.00 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,536.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,567.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,744.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,634.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,071.08
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,116.00
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,567.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,292.80
|
| Rate for Payer: The Alliance Commercial |
$21,952.00
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON A38 5551-G-381
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
3219469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,536.64 |
| Max. Negotiated Rate |
$21,952.00 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,536.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,567.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,744.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,634.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,071.08
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,116.00
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,567.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,292.80
|
| Rate for Payer: The Alliance Commercial |
$21,952.00
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON A38 5551-G-381
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
3219469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,689.12 |
| Max. Negotiated Rate |
$5,048.96 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,292.80
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON S27MM 5550-G-278
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
4493941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,689.12 |
| Max. Negotiated Rate |
$5,048.96 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,292.80
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON S27MM 5550-G-278
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
4493941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,536.64 |
| Max. Negotiated Rate |
$21,952.00 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,536.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,567.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,744.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,634.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,071.08
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,116.00
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,567.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,292.80
|
| Rate for Payer: The Alliance Commercial |
$21,952.00
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON S29MM 5550-G-298
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
4099057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.51 |
| Max. Negotiated Rate |
$5,243.08 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,419.40
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
PATELLA TRIATHLON S29MM 5550-G-298
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
4099057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,595.72 |
| Max. Negotiated Rate |
$22,796.00 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,595.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,704.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,849.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,735.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,189.16
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,274.25
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,704.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,419.40
|
| Rate for Payer: The Alliance Commercial |
$22,796.00
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
