|
ARTICULAR SURFACE EF 3-4 20MM PROLONG 5962-32-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967606
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 3-4 23MM PROLONG 5962-32-23
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967607
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 3-4 23MM PROLONG 5962-32-23
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967607
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 10MM PROLONG 5962-40-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 10MM PROLONG 5962-40-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 14MM PROLONG 5962-40-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 14MM PROLONG 5962-40-14
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 17MM PROLONG 5962-40-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967611
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 17MM PROLONG 5962-40-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967611
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 20MM PROLONG 5962-40-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 20MM PROLONG 5962-40-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 23MM PROLONG 5962-40-23
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 5-6 23MM PROLONG 5962-40-23
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 10MM PROLONG 5962-51-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967614
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 10MM PROLONG 5962-51-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967614
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 12MM PROLONG 5962-51-12
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967615
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 12MM PROLONG 5962-51-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967615
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 14MM PROLONG 5962-51-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967616
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 14MM PROLONG 5962-51-14
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967616
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 17MM PROLONG 5962-51-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 17MM PROLONG 5962-51-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 20MM PROLONG 5962-51-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967618
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 20MM PROLONG 5962-51-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967618
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 23MM PROLONG 5962-51-23
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE EF 7-10 23MM PROLONG 5962-51-23
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$36,044.00 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: The Alliance Commercial |
$36,044.00
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
