|
PATELLA BLADE 41MM 00-5979-095-41
|
Facility
|
OP
|
$3,022.00
|
|
| Hospital Charge Code |
2967773
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$880.01 |
| Max. Negotiated Rate |
$2,891.45 |
| Rate for Payer: Aetna Commercial |
$2,828.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,702.88
|
| Rate for Payer: Aetna Managed Medicare |
$880.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,042.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,571.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,508.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,665.73
|
| Rate for Payer: Cash Price |
$906.60
|
| Rate for Payer: Cigna Commercial |
$2,891.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,758.80
|
| Rate for Payer: Health EOS Commercial |
$2,797.16
|
| Rate for Payer: HFN Commercial |
$2,891.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,357.16
|
| Rate for Payer: Multiplan Commercial |
$2,514.30
|
| Rate for Payer: NAPHCARE Commercial |
$1,885.73
|
| Rate for Payer: Preferred Network Access Commercial |
$2,891.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,540.01
|
| Rate for Payer: Quartz Commercial |
$2,042.87
|
| Rate for Payer: Quartz Medicare Advantage |
$1,885.73
|
| Rate for Payer: The Alliance Commercial |
$1,571.44
|
| Rate for Payer: WEA Trust Commercial |
$1,728.58
|
| Rate for Payer: WPS Commercial |
$2,327.85
|
|
|
PATELLA BLADE 41MM 00-5979-095-41
|
Facility
|
IP
|
$3,022.00
|
|
| Hospital Charge Code |
2967773
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,540.01 |
| Max. Negotiated Rate |
$2,891.45 |
| Rate for Payer: Aetna Commercial |
$2,828.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,702.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,665.73
|
| Rate for Payer: Cash Price |
$906.60
|
| Rate for Payer: Cigna Commercial |
$2,891.45
|
| Rate for Payer: Health EOS Commercial |
$2,797.16
|
| Rate for Payer: HFN Commercial |
$2,891.45
|
| Rate for Payer: Multiplan Commercial |
$2,514.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,891.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,540.01
|
| Rate for Payer: Quartz Commercial |
$1,885.73
|
| Rate for Payer: WEA Trust Commercial |
$1,728.58
|
| Rate for Payer: WPS Commercial |
$2,327.85
|
|
|
PATELLA BLADE 46MM 00-5979-095-46
|
Facility
|
OP
|
$3,022.00
|
|
| Hospital Charge Code |
2967774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$880.01 |
| Max. Negotiated Rate |
$2,891.45 |
| Rate for Payer: Aetna Commercial |
$2,828.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,702.88
|
| Rate for Payer: Aetna Managed Medicare |
$880.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,042.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,571.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,508.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,665.73
|
| Rate for Payer: Cash Price |
$906.60
|
| Rate for Payer: Cigna Commercial |
$2,891.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,758.80
|
| Rate for Payer: Health EOS Commercial |
$2,797.16
|
| Rate for Payer: HFN Commercial |
$2,891.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,357.16
|
| Rate for Payer: Multiplan Commercial |
$2,514.30
|
| Rate for Payer: NAPHCARE Commercial |
$1,885.73
|
| Rate for Payer: Preferred Network Access Commercial |
$2,891.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,540.01
|
| Rate for Payer: Quartz Commercial |
$2,042.87
|
| Rate for Payer: Quartz Medicare Advantage |
$1,885.73
|
| Rate for Payer: The Alliance Commercial |
$1,571.44
|
| Rate for Payer: WEA Trust Commercial |
$1,728.58
|
| Rate for Payer: WPS Commercial |
$2,327.85
|
|
|
PATELLA BLADE 46MM 00-5979-095-46
|
Facility
|
IP
|
$3,022.00
|
|
| Hospital Charge Code |
2967774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,540.01 |
| Max. Negotiated Rate |
$2,891.45 |
| Rate for Payer: Aetna Commercial |
$2,828.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,702.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,665.73
|
| Rate for Payer: Cash Price |
$906.60
|
| Rate for Payer: Cigna Commercial |
$2,891.45
|
| Rate for Payer: Health EOS Commercial |
$2,797.16
|
| Rate for Payer: HFN Commercial |
$2,891.45
|
| Rate for Payer: Multiplan Commercial |
$2,514.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,891.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,540.01
|
| Rate for Payer: Quartz Commercial |
$1,885.73
|
| Rate for Payer: WEA Trust Commercial |
$1,728.58
|
| Rate for Payer: WPS Commercial |
$2,327.85
|
|
|
PATELLA BLADE 51MM 00-5979-095-51
|
Facility
|
IP
|
$3,022.00
|
|
| Hospital Charge Code |
2967775
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,540.01 |
| Max. Negotiated Rate |
$2,891.45 |
| Rate for Payer: Aetna Commercial |
$2,828.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,702.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,665.73
|
| Rate for Payer: Cash Price |
$906.60
|
| Rate for Payer: Cigna Commercial |
$2,891.45
|
| Rate for Payer: Health EOS Commercial |
$2,797.16
|
| Rate for Payer: HFN Commercial |
$2,891.45
|
| Rate for Payer: Multiplan Commercial |
$2,514.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,891.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,540.01
|
| Rate for Payer: Quartz Commercial |
$1,885.73
|
| Rate for Payer: WEA Trust Commercial |
$1,728.58
|
| Rate for Payer: WPS Commercial |
$2,327.85
|
|
|
PATELLA BLADE 51MM 00-5979-095-51
|
Facility
|
OP
|
$3,022.00
|
|
| Hospital Charge Code |
2967775
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$880.01 |
| Max. Negotiated Rate |
$2,891.45 |
| Rate for Payer: Aetna Commercial |
$2,828.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,702.88
|
| Rate for Payer: Aetna Managed Medicare |
$880.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,042.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,571.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,508.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,665.73
|
| Rate for Payer: Cash Price |
$906.60
|
| Rate for Payer: Cigna Commercial |
$2,891.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,758.80
|
| Rate for Payer: Health EOS Commercial |
$2,797.16
|
| Rate for Payer: HFN Commercial |
$2,891.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,357.16
|
| Rate for Payer: Multiplan Commercial |
$2,514.30
|
| Rate for Payer: NAPHCARE Commercial |
$1,885.73
|
| Rate for Payer: Preferred Network Access Commercial |
$2,891.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,540.01
|
| Rate for Payer: Quartz Commercial |
$2,042.87
|
| Rate for Payer: Quartz Medicare Advantage |
$1,885.73
|
| Rate for Payer: The Alliance Commercial |
$1,571.44
|
| Rate for Payer: WEA Trust Commercial |
$1,728.58
|
| Rate for Payer: WPS Commercial |
$2,327.85
|
|
|
PATELLA FEMORAL JOINT ARTHROPLASTY
|
Facility
|
OP
|
$13,291.00
|
|
| Hospital Charge Code |
4494581
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,870.34 |
| Max. Negotiated Rate |
$12,716.83 |
| Rate for Payer: Aetna Commercial |
$12,440.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,887.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,870.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,984.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,911.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,326.00
|
| Rate for Payer: Cash Price |
$3,987.30
|
| Rate for Payer: Cigna Commercial |
$12,716.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,735.36
|
| Rate for Payer: Health EOS Commercial |
$12,302.15
|
| Rate for Payer: HFN Commercial |
$12,716.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,366.98
|
| Rate for Payer: Multiplan Commercial |
$11,058.11
|
| Rate for Payer: NAPHCARE Commercial |
$8,293.58
|
| Rate for Payer: Preferred Network Access Commercial |
$12,716.83
|
| Rate for Payer: Quartz Beloit One Network |
$6,773.09
|
| Rate for Payer: Quartz Commercial |
$8,984.72
|
| Rate for Payer: Quartz Medicare Advantage |
$8,293.58
|
| Rate for Payer: The Alliance Commercial |
$6,911.32
|
| Rate for Payer: WEA Trust Commercial |
$7,602.45
|
| Rate for Payer: WPS Commercial |
$10,238.06
|
|
|
PATELLA FEMORAL JOINT ARTHROPLASTY
|
Facility
|
IP
|
$13,291.00
|
|
| Hospital Charge Code |
4494581
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,773.09 |
| Max. Negotiated Rate |
$12,716.83 |
| Rate for Payer: Aetna Commercial |
$12,440.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,887.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,326.00
|
| Rate for Payer: Cash Price |
$3,987.30
|
| Rate for Payer: Cigna Commercial |
$12,716.83
|
| Rate for Payer: Health EOS Commercial |
$12,302.15
|
| Rate for Payer: HFN Commercial |
$12,716.83
|
| Rate for Payer: Multiplan Commercial |
$11,058.11
|
| Rate for Payer: Preferred Network Access Commercial |
$12,716.83
|
| Rate for Payer: Quartz Beloit One Network |
$6,773.09
|
| Rate for Payer: Quartz Commercial |
$8,293.58
|
| Rate for Payer: WEA Trust Commercial |
$7,602.45
|
| Rate for Payer: WPS Commercial |
$10,238.06
|
|
|
PATELLA PERSONA ALL POLY 29MM 42-5400-000-29
|
Facility
|
OP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3116528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,224.20 |
| Max. Negotiated Rate |
$4,022.39 |
| Rate for Payer: Aetna Commercial |
$3,934.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,760.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,224.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,841.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,186.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,098.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,317.24
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$4,022.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,446.73
|
| Rate for Payer: Health EOS Commercial |
$3,891.22
|
| Rate for Payer: HFN Commercial |
$4,022.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,279.12
|
| Rate for Payer: Multiplan Commercial |
$3,497.73
|
| Rate for Payer: NAPHCARE Commercial |
$2,623.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,022.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,142.36
|
| Rate for Payer: Quartz Commercial |
$2,841.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,623.30
|
| Rate for Payer: The Alliance Commercial |
$2,186.08
|
| Rate for Payer: WEA Trust Commercial |
$2,404.69
|
| Rate for Payer: WPS Commercial |
$3,238.34
|
|
|
PATELLA PERSONA ALL POLY 29MM 42-5400-000-29
|
Facility
|
IP
|
$4,204.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3116528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.36 |
| Max. Negotiated Rate |
$4,022.39 |
| Rate for Payer: Aetna Commercial |
$3,934.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,760.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,317.24
|
| Rate for Payer: Cash Price |
$1,261.20
|
| Rate for Payer: Cigna Commercial |
$4,022.39
|
| Rate for Payer: Health EOS Commercial |
$3,891.22
|
| Rate for Payer: HFN Commercial |
$4,022.39
|
| Rate for Payer: Multiplan Commercial |
$3,497.73
|
| Rate for Payer: Preferred Network Access Commercial |
$4,022.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,142.36
|
| Rate for Payer: Quartz Commercial |
$2,623.30
|
| Rate for Payer: WEA Trust Commercial |
$2,404.69
|
| Rate for Payer: WPS Commercial |
$3,238.34
|
|
|
PATELLA PERSONA ALL POLY 32MM 42-5400-000-32
|
Facility
|
OP
|
$4,357.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221473
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,268.76 |
| Max. Negotiated Rate |
$4,168.78 |
| Rate for Payer: Aetna Commercial |
$4,078.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,896.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,268.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,945.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,265.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,175.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,401.58
|
| Rate for Payer: Cash Price |
$1,307.10
|
| Rate for Payer: Cigna Commercial |
$4,168.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,535.77
|
| Rate for Payer: Health EOS Commercial |
$4,032.84
|
| Rate for Payer: HFN Commercial |
$4,168.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,398.46
|
| Rate for Payer: Multiplan Commercial |
$3,625.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,718.77
|
| Rate for Payer: Preferred Network Access Commercial |
$4,168.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,220.33
|
| Rate for Payer: Quartz Commercial |
$2,945.33
|
| Rate for Payer: Quartz Medicare Advantage |
$2,718.77
|
| Rate for Payer: The Alliance Commercial |
$2,265.64
|
| Rate for Payer: WEA Trust Commercial |
$2,492.20
|
| Rate for Payer: WPS Commercial |
$3,356.20
|
|
|
PATELLA PERSONA ALL POLY 32MM 42-5400-000-32
|
Facility
|
IP
|
$4,357.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221473
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,220.33 |
| Max. Negotiated Rate |
$4,168.78 |
| Rate for Payer: Aetna Commercial |
$4,078.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,896.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,401.58
|
| Rate for Payer: Cash Price |
$1,307.10
|
| Rate for Payer: Cigna Commercial |
$4,168.78
|
| Rate for Payer: Health EOS Commercial |
$4,032.84
|
| Rate for Payer: HFN Commercial |
$4,168.78
|
| Rate for Payer: Multiplan Commercial |
$3,625.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,168.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,220.33
|
| Rate for Payer: Quartz Commercial |
$2,718.77
|
| Rate for Payer: WEA Trust Commercial |
$2,492.20
|
| Rate for Payer: WPS Commercial |
$3,356.20
|
|
|
PATELLA PERSONA VE 29MM 42-5402-000-29
|
Facility
|
OP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,019.47 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,019.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,688.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,606.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,461.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,036.17
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,409.30
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: NAPHCARE Commercial |
$4,327.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,688.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,327.44
|
| Rate for Payer: The Alliance Commercial |
$3,606.20
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
PATELLA PERSONA VE 29MM 42-5402-000-29
|
Facility
|
IP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,534.08 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,327.44
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
PATELLA PERSONA VE 32MM 42-5402-000-32
|
Facility
|
OP
|
$6,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177471
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,019.47 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,019.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,688.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,606.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,461.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,036.17
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,409.30
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: NAPHCARE Commercial |
$4,327.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,688.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,327.44
|
| Rate for Payer: The Alliance Commercial |
$3,606.20
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
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 |
$3,534.08 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,327.44
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
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 |
$3,534.08 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,327.44
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
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 |
$2,019.47 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,019.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,688.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,606.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,461.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,036.17
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,409.30
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: NAPHCARE Commercial |
$4,327.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,688.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,327.44
|
| Rate for Payer: The Alliance Commercial |
$3,606.20
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
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 |
$2,019.47 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,019.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,688.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,606.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,461.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,036.17
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,409.30
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: NAPHCARE Commercial |
$4,327.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,688.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,327.44
|
| Rate for Payer: The Alliance Commercial |
$3,606.20
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
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 |
$3,534.08 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,327.44
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
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 |
$2,019.47 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,019.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,688.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,606.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,461.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,036.17
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,409.30
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: NAPHCARE Commercial |
$4,327.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,688.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,327.44
|
| Rate for Payer: The Alliance Commercial |
$3,606.20
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
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 |
$3,534.08 |
| Max. Negotiated Rate |
$6,635.41 |
| Rate for Payer: Aetna Commercial |
$6,491.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,202.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,822.57
|
| Rate for Payer: Cash Price |
$2,080.50
|
| Rate for Payer: Cigna Commercial |
$6,635.41
|
| Rate for Payer: Health EOS Commercial |
$6,419.04
|
| Rate for Payer: HFN Commercial |
$6,635.41
|
| Rate for Payer: Multiplan Commercial |
$5,769.92
|
| Rate for Payer: Preferred Network Access Commercial |
$6,635.41
|
| Rate for Payer: Quartz Beloit One Network |
$3,534.08
|
| Rate for Payer: Quartz Commercial |
$4,327.44
|
| Rate for Payer: WEA Trust Commercial |
$3,966.82
|
| Rate for Payer: WPS Commercial |
$5,342.03
|
|
|
PATELLAR COMPONENT 32mm 71420576
|
Facility
|
OP
|
$6,772.00
|
|
| Hospital Charge Code |
2966029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,972.01 |
| Max. Negotiated Rate |
$6,479.45 |
| Rate for Payer: Aetna Commercial |
$6,338.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,056.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,972.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,577.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,521.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,380.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,732.73
|
| Rate for Payer: Cash Price |
$2,031.60
|
| Rate for Payer: Cigna Commercial |
$6,479.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,941.30
|
| Rate for Payer: Health EOS Commercial |
$6,268.16
|
| Rate for Payer: HFN Commercial |
$6,479.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,282.16
|
| Rate for Payer: Multiplan Commercial |
$5,634.30
|
| Rate for Payer: NAPHCARE Commercial |
$4,225.73
|
| Rate for Payer: Preferred Network Access Commercial |
$6,479.45
|
| Rate for Payer: Quartz Beloit One Network |
$3,451.01
|
| Rate for Payer: Quartz Commercial |
$4,577.87
|
| Rate for Payer: Quartz Medicare Advantage |
$4,225.73
|
| Rate for Payer: The Alliance Commercial |
$3,521.44
|
| Rate for Payer: WEA Trust Commercial |
$3,873.58
|
| Rate for Payer: WPS Commercial |
$5,216.47
|
|
|
PATELLAR COMPONENT 32mm 71420576
|
Facility
|
IP
|
$6,772.00
|
|
| Hospital Charge Code |
2966029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,451.01 |
| Max. Negotiated Rate |
$6,479.45 |
| Rate for Payer: Aetna Commercial |
$6,338.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,056.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,732.73
|
| Rate for Payer: Cash Price |
$2,031.60
|
| Rate for Payer: Cigna Commercial |
$6,479.45
|
| Rate for Payer: Health EOS Commercial |
$6,268.16
|
| Rate for Payer: HFN Commercial |
$6,479.45
|
| Rate for Payer: Multiplan Commercial |
$5,634.30
|
| Rate for Payer: Preferred Network Access Commercial |
$6,479.45
|
| Rate for Payer: Quartz Beloit One Network |
$3,451.01
|
| Rate for Payer: Quartz Commercial |
$4,225.73
|
| Rate for Payer: WEA Trust Commercial |
$3,873.58
|
| Rate for Payer: WPS Commercial |
$5,216.47
|
|
|
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 |
$2,150.00 |
| Max. Negotiated Rate |
$4,036.74 |
| Rate for Payer: Aetna Commercial |
$3,948.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,773.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,325.51
|
| Rate for Payer: Cash Price |
$1,265.70
|
| Rate for Payer: Cigna Commercial |
$4,036.74
|
| Rate for Payer: Health EOS Commercial |
$3,905.11
|
| Rate for Payer: HFN Commercial |
$4,036.74
|
| Rate for Payer: Multiplan Commercial |
$3,510.21
|
| Rate for Payer: Preferred Network Access Commercial |
$4,036.74
|
| Rate for Payer: Quartz Beloit One Network |
$2,150.00
|
| Rate for Payer: Quartz Commercial |
$2,632.66
|
| Rate for Payer: WEA Trust Commercial |
$2,413.27
|
| Rate for Payer: WPS Commercial |
$3,249.90
|
|
