|
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 |
$1,228.57 |
| 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: Aetna Managed Medicare |
$1,228.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,852.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,193.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,106.12
|
| 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: Dean Health DHI/DHP/ASO |
$2,455.46
|
| Rate for Payer: Health EOS Commercial |
$3,905.11
|
| Rate for Payer: HFN Commercial |
$4,036.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,290.82
|
| Rate for Payer: Multiplan Commercial |
$3,510.21
|
| Rate for Payer: NAPHCARE Commercial |
$2,632.66
|
| 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 |
$2,852.04
|
| Rate for Payer: Quartz Medicare Advantage |
$2,632.66
|
| Rate for Payer: The Alliance Commercial |
$2,193.88
|
| Rate for Payer: WEA Trust Commercial |
$2,413.27
|
| Rate for Payer: WPS Commercial |
$3,249.90
|
|
|
PATELLA TENDON REPAIR, RUPTURED
|
Facility
|
OP
|
$4,912.00
|
|
| Hospital Charge Code |
2960535
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,430.37 |
| Max. Negotiated Rate |
$4,699.80 |
| Rate for Payer: Aetna Commercial |
$4,597.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,393.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,430.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,320.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,554.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,452.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,707.49
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,699.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,858.78
|
| Rate for Payer: Health EOS Commercial |
$4,546.55
|
| Rate for Payer: HFN Commercial |
$4,699.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,831.36
|
| Rate for Payer: Multiplan Commercial |
$4,086.78
|
| Rate for Payer: NAPHCARE Commercial |
$3,065.09
|
| Rate for Payer: Preferred Network Access Commercial |
$4,699.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,503.16
|
| Rate for Payer: Quartz Commercial |
$3,320.51
|
| Rate for Payer: Quartz Medicare Advantage |
$3,065.09
|
| Rate for Payer: The Alliance Commercial |
$2,554.24
|
| Rate for Payer: WEA Trust Commercial |
$2,809.66
|
| Rate for Payer: WPS Commercial |
$3,783.71
|
|
|
PATELLA TENDON REPAIR, RUPTURED
|
Facility
|
IP
|
$4,912.00
|
|
| Hospital Charge Code |
2960535
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,503.16 |
| Max. Negotiated Rate |
$4,699.80 |
| Rate for Payer: Aetna Commercial |
$4,597.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,393.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,707.49
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,699.80
|
| Rate for Payer: Health EOS Commercial |
$4,546.55
|
| Rate for Payer: HFN Commercial |
$4,699.80
|
| Rate for Payer: Multiplan Commercial |
$4,086.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,699.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,503.16
|
| Rate for Payer: Quartz Commercial |
$3,065.09
|
| Rate for Payer: WEA Trust Commercial |
$2,809.66
|
| Rate for Payer: WPS Commercial |
$3,783.71
|
|
|
PATELLA TRIATHLON A29 5551-G-299
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
3072400
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,598.11 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,598.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,709.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,853.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,739.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,194.02
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,280.64
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: NAPHCARE Commercial |
$3,424.51
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,709.89
|
| Rate for Payer: Quartz Medicare Advantage |
$3,424.51
|
| Rate for Payer: The Alliance Commercial |
$2,853.76
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON A29 5551-G-299
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
3072400
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,796.68 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,424.51
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON A32 5551-G-320
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
3177479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,598.11 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,598.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,709.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,853.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,739.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,194.02
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,280.64
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: NAPHCARE Commercial |
$3,424.51
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,709.89
|
| Rate for Payer: Quartz Medicare Advantage |
$3,424.51
|
| Rate for Payer: The Alliance Commercial |
$2,853.76
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON A32 5551-G-320
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
3177479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,796.68 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,424.51
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON A35 5551-G-350
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
3127477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,796.68 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,424.51
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON A35 5551-G-350
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
3127477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,598.11 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,598.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,709.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,853.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,739.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,194.02
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,280.64
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: NAPHCARE Commercial |
$3,424.51
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,709.89
|
| Rate for Payer: Quartz Medicare Advantage |
$3,424.51
|
| Rate for Payer: The Alliance Commercial |
$2,853.76
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON A38 5551-G-381
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
3219469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,796.68 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,424.51
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON A38 5551-G-381
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
3219469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,598.11 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,598.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,709.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,853.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,739.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,194.02
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,280.64
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: NAPHCARE Commercial |
$3,424.51
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,709.89
|
| Rate for Payer: Quartz Medicare Advantage |
$3,424.51
|
| Rate for Payer: The Alliance Commercial |
$2,853.76
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON S27MM 5550-G-278
|
Facility
|
OP
|
$5,488.00
|
|
| Hospital Charge Code |
4493941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,598.11 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,598.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,709.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,853.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,739.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,194.02
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,280.64
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: NAPHCARE Commercial |
$3,424.51
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,709.89
|
| Rate for Payer: Quartz Medicare Advantage |
$3,424.51
|
| Rate for Payer: The Alliance Commercial |
$2,853.76
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON S27MM 5550-G-278
|
Facility
|
IP
|
$5,488.00
|
|
| Hospital Charge Code |
4493941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,796.68 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,424.51
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON S29MM 5550-G-298
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
4099057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,659.55 |
| Max. Negotiated Rate |
$5,452.80 |
| Rate for Payer: Aetna Commercial |
$5,334.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,097.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,659.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,852.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,963.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,844.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.29
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,452.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,316.82
|
| Rate for Payer: Health EOS Commercial |
$5,274.99
|
| Rate for Payer: HFN Commercial |
$5,452.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,445.22
|
| Rate for Payer: Multiplan Commercial |
$4,741.57
|
| Rate for Payer: NAPHCARE Commercial |
$3,556.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,452.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.21
|
| Rate for Payer: Quartz Commercial |
$3,852.52
|
| Rate for Payer: Quartz Medicare Advantage |
$3,556.18
|
| Rate for Payer: The Alliance Commercial |
$2,963.48
|
| Rate for Payer: WEA Trust Commercial |
$3,259.83
|
| Rate for Payer: WPS Commercial |
$4,389.94
|
|
|
PATELLA TRIATHLON S29MM 5550-G-298
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
4099057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,904.21 |
| Max. Negotiated Rate |
$5,452.80 |
| Rate for Payer: Aetna Commercial |
$5,334.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,097.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.29
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,452.80
|
| Rate for Payer: Health EOS Commercial |
$5,274.99
|
| Rate for Payer: HFN Commercial |
$5,452.80
|
| Rate for Payer: Multiplan Commercial |
$4,741.57
|
| Rate for Payer: Preferred Network Access Commercial |
$5,452.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.21
|
| Rate for Payer: Quartz Commercial |
$3,556.18
|
| Rate for Payer: WEA Trust Commercial |
$3,259.83
|
| Rate for Payer: WPS Commercial |
$4,389.94
|
|
|
PATELLA TRIATHLON S39MM 5550-G-391
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
4100376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,659.55 |
| Max. Negotiated Rate |
$5,452.80 |
| Rate for Payer: Aetna Commercial |
$5,334.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,097.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,659.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,852.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,963.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,844.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.29
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,452.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,316.82
|
| Rate for Payer: Health EOS Commercial |
$5,274.99
|
| Rate for Payer: HFN Commercial |
$5,452.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,445.22
|
| Rate for Payer: Multiplan Commercial |
$4,741.57
|
| Rate for Payer: NAPHCARE Commercial |
$3,556.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,452.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.21
|
| Rate for Payer: Quartz Commercial |
$3,852.52
|
| Rate for Payer: Quartz Medicare Advantage |
$3,556.18
|
| Rate for Payer: The Alliance Commercial |
$2,963.48
|
| Rate for Payer: WEA Trust Commercial |
$3,259.83
|
| Rate for Payer: WPS Commercial |
$4,389.94
|
|
|
PATELLA TRIATHLON S39MM 5550-G-391
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
4100376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,904.21 |
| Max. Negotiated Rate |
$5,452.80 |
| Rate for Payer: Aetna Commercial |
$5,334.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,097.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.29
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,452.80
|
| Rate for Payer: Health EOS Commercial |
$5,274.99
|
| Rate for Payer: HFN Commercial |
$5,452.80
|
| Rate for Payer: Multiplan Commercial |
$4,741.57
|
| Rate for Payer: Preferred Network Access Commercial |
$5,452.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.21
|
| Rate for Payer: Quartz Commercial |
$3,556.18
|
| Rate for Payer: WEA Trust Commercial |
$3,259.83
|
| Rate for Payer: WPS Commercial |
$4,389.94
|
|
|
PATELLA TRIATHLON SZ 36MM 5550-G-360
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
3935332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,659.55 |
| Max. Negotiated Rate |
$5,452.80 |
| Rate for Payer: Aetna Commercial |
$5,334.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,097.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,659.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,852.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,963.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,844.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.29
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,452.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,316.82
|
| Rate for Payer: Health EOS Commercial |
$5,274.99
|
| Rate for Payer: HFN Commercial |
$5,452.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,445.22
|
| Rate for Payer: Multiplan Commercial |
$4,741.57
|
| Rate for Payer: NAPHCARE Commercial |
$3,556.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,452.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.21
|
| Rate for Payer: Quartz Commercial |
$3,852.52
|
| Rate for Payer: Quartz Medicare Advantage |
$3,556.18
|
| Rate for Payer: The Alliance Commercial |
$2,963.48
|
| Rate for Payer: WEA Trust Commercial |
$3,259.83
|
| Rate for Payer: WPS Commercial |
$4,389.94
|
|
|
PATELLA TRIATHLON SZ 36MM 5550-G-360
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
3935332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,904.21 |
| Max. Negotiated Rate |
$5,452.80 |
| Rate for Payer: Aetna Commercial |
$5,334.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,097.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.29
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,452.80
|
| Rate for Payer: Health EOS Commercial |
$5,274.99
|
| Rate for Payer: HFN Commercial |
$5,452.80
|
| Rate for Payer: Multiplan Commercial |
$4,741.57
|
| Rate for Payer: Preferred Network Access Commercial |
$5,452.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.21
|
| Rate for Payer: Quartz Commercial |
$3,556.18
|
| Rate for Payer: WEA Trust Commercial |
$3,259.83
|
| Rate for Payer: WPS Commercial |
$4,389.94
|
|
|
PATELLA TRIATHLON SZ S31MM 5550-G-319
|
Facility
|
IP
|
$5,488.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,796.68 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,424.51
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON SZ S31MM 5550-G-319
|
Facility
|
OP
|
$5,488.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,598.11 |
| Max. Negotiated Rate |
$5,250.92 |
| Rate for Payer: Aetna Commercial |
$5,136.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,908.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,598.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,709.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,853.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,739.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,024.99
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,250.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,194.02
|
| Rate for Payer: Health EOS Commercial |
$5,079.69
|
| Rate for Payer: HFN Commercial |
$5,250.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,280.64
|
| Rate for Payer: Multiplan Commercial |
$4,566.02
|
| Rate for Payer: NAPHCARE Commercial |
$3,424.51
|
| Rate for Payer: Preferred Network Access Commercial |
$5,250.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,796.68
|
| Rate for Payer: Quartz Commercial |
$3,709.89
|
| Rate for Payer: Quartz Medicare Advantage |
$3,424.51
|
| Rate for Payer: The Alliance Commercial |
$2,853.76
|
| Rate for Payer: WEA Trust Commercial |
$3,139.14
|
| Rate for Payer: WPS Commercial |
$4,227.41
|
|
|
PATELLA TRIATHLON SZ S33MM 5550-G-339
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
3779518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,659.55 |
| Max. Negotiated Rate |
$5,452.80 |
| Rate for Payer: Aetna Commercial |
$5,334.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,097.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,659.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,852.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,963.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,844.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.29
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,452.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,316.82
|
| Rate for Payer: Health EOS Commercial |
$5,274.99
|
| Rate for Payer: HFN Commercial |
$5,452.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,445.22
|
| Rate for Payer: Multiplan Commercial |
$4,741.57
|
| Rate for Payer: NAPHCARE Commercial |
$3,556.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,452.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.21
|
| Rate for Payer: Quartz Commercial |
$3,852.52
|
| Rate for Payer: Quartz Medicare Advantage |
$3,556.18
|
| Rate for Payer: The Alliance Commercial |
$2,963.48
|
| Rate for Payer: WEA Trust Commercial |
$3,259.83
|
| Rate for Payer: WPS Commercial |
$4,389.94
|
|
|
PATELLA TRIATHLON SZ S33MM 5550-G-339
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
3779518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,904.21 |
| Max. Negotiated Rate |
$5,452.80 |
| Rate for Payer: Aetna Commercial |
$5,334.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,097.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,141.29
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,452.80
|
| Rate for Payer: Health EOS Commercial |
$5,274.99
|
| Rate for Payer: HFN Commercial |
$5,452.80
|
| Rate for Payer: Multiplan Commercial |
$4,741.57
|
| Rate for Payer: Preferred Network Access Commercial |
$5,452.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,904.21
|
| Rate for Payer: Quartz Commercial |
$3,556.18
|
| Rate for Payer: WEA Trust Commercial |
$3,259.83
|
| Rate for Payer: WPS Commercial |
$4,389.94
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC
|
Facility
|
IP
|
$30,490.72
|
|
|
Service Code
|
MSDRG 543
|
| Min. Negotiated Rate |
$8,379.40 |
| Max. Negotiated Rate |
$30,490.72 |
| Rate for Payer: Aetna Managed Medicare |
$8,379.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,430.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,192.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,334.02
|
| Rate for Payer: Anthem Medicare Advantage |
$8,379.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,379.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,379.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,379.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,132.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,379.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22,119.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,379.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,379.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,379.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,379.40
|
| Rate for Payer: NAPHCARE Commercial |
$12,569.11
|
| Rate for Payer: Quartz Medicare Advantage |
$8,379.40
|
| Rate for Payer: The Alliance Commercial |
$30,490.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,379.40
|
| Rate for Payer: United Healthcare PPO |
$17,220.24
|
| Rate for Payer: Wellcare Medicare |
$8,379.40
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$50,757.20
|
|
|
Service Code
|
MSDRG 542
|
| Min. Negotiated Rate |
$14,034.98 |
| Max. Negotiated Rate |
$50,757.20 |
| Rate for Payer: Aetna Managed Medicare |
$14,034.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,543.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,543.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,068.13
|
| Rate for Payer: Anthem Medicare Advantage |
$14,034.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,034.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,034.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,034.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,158.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,034.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36,984.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,034.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,034.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,034.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,034.98
|
| Rate for Payer: NAPHCARE Commercial |
$21,052.47
|
| Rate for Payer: Quartz Medicare Advantage |
$14,034.98
|
| Rate for Payer: The Alliance Commercial |
$50,757.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,034.98
|
| Rate for Payer: United Healthcare PPO |
$28,793.01
|
| Rate for Payer: Wellcare Medicare |
$14,034.98
|
|
