|
ARTICULAR SURFACE GH 5-6 10MM PROLONG 5962-42-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967620
|
|
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 GH 5-6 10MM PROLONG 5962-42-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967620
|
|
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 GH 5-6 12MM PROLONG 5962-42-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967621
|
|
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 GH 5-6 12MM PROLONG 5962-42-12
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967621
|
|
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 GH 5-6 17MM PROLONG 5962-42-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967623
|
|
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 GH 5-6 17MM PROLONG 5962-42-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967623
|
|
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 GH 5-6 20MM PROLONG 5962-42-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967624
|
|
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 GH 5-6 20MM PROLONG 5962-42-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967624
|
|
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 GH 5-6 23MM PROLONG 5962-42-23
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967625
|
|
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 GH 5-6 23MM PROLONG 5962-42-23
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967625
|
|
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 GH 7-10 10MM PROLONG 5962-50-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967626
|
|
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 GH 7-10 10MM PROLONG 5962-50-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967626
|
|
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 GH 7-10 12MM PROLONG 5962-50-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967627
|
|
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 GH 7-10 12MM PROLONG 5962-50-12
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967627
|
|
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 GH 7-10 14MM PROLONG 5962-50-14
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967628
|
|
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 GH 7-10 14MM PROLONG 5962-50-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967628
|
|
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 GH 7-10 17MM PROLONG 5962-50-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967629
|
|
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 GH 7-10 17MM PROLONG 5962-50-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967629
|
|
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 GH 7-10 20MM PROLONG 5962-50-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967630
|
|
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 GH 7-10 20MM PROLONG 5962-50-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967630
|
|
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 GH 7-10 23MM PROLONG 5962-50-23
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967631
|
|
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 GH 7-10 23MM PROLONG 5962-50-23
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967631
|
|
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 GREEN EF 10MM LCCK 5994-40-10
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,897.44 |
| Max. Negotiated Rate |
$41,392.00 |
| Rate for Payer: Aetna Commercial |
$9,313.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,899.28
|
| Rate for Payer: Aetna Managed Medicare |
$2,897.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,726.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,174.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,967.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,484.44
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,520.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,790.74
|
| Rate for Payer: Health EOS Commercial |
$9,209.72
|
| Rate for Payer: HFN Commercial |
$9,520.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,761.00
|
| Rate for Payer: Multiplan Commercial |
$8,278.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,208.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,520.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,070.52
|
| Rate for Payer: Quartz Commercial |
$6,726.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,208.80
|
| Rate for Payer: The Alliance Commercial |
$41,392.00
|
| Rate for Payer: WEA Trust Commercial |
$5,691.40
|
| Rate for Payer: WPS Commercial |
$7,664.76
|
|
|
ARTICULAR SURFACE GREEN EF 10MM LCCK 5994-40-10
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,070.52 |
| Max. Negotiated Rate |
$9,520.16 |
| Rate for Payer: Aetna Commercial |
$9,313.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,899.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,484.44
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,520.16
|
| Rate for Payer: Health EOS Commercial |
$9,209.72
|
| Rate for Payer: HFN Commercial |
$9,520.16
|
| Rate for Payer: Multiplan Commercial |
$8,278.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,208.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,520.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,070.52
|
| Rate for Payer: Quartz Commercial |
$6,208.80
|
| Rate for Payer: WEA Trust Commercial |
$5,691.40
|
| Rate for Payer: WPS Commercial |
$7,664.76
|
|
|
ARTICULAR SURFACE GREEN EF 12MM LCCK 5994-40-12
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973985
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,070.52 |
| Max. Negotiated Rate |
$9,520.16 |
| Rate for Payer: Aetna Commercial |
$9,313.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,899.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,484.44
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,520.16
|
| Rate for Payer: Health EOS Commercial |
$9,209.72
|
| Rate for Payer: HFN Commercial |
$9,520.16
|
| Rate for Payer: Multiplan Commercial |
$8,278.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,208.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,520.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,070.52
|
| Rate for Payer: Quartz Commercial |
$6,208.80
|
| Rate for Payer: WEA Trust Commercial |
$5,691.40
|
| Rate for Payer: WPS Commercial |
$7,664.76
|
|
