|
ARTICULAR SURFACE CD 1-2 14MM 5964-22-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967444
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 1-2 17MM 5964-22-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 1-2 17MM 5964-22-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 1-2 20MM 5964-22-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967446
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 1-2 20MM 5964-22-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967446
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 10MM PROLONG 5962-30-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967575
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 10MM PROLONG 5962-30-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967575
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 12MM PROLONG 5962-30-12
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967576
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 12MM PROLONG 5962-30-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967576
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD3-4 14MM PROLONG 5962-30-14
|
Facility
|
OP
|
$9,358.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967577
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,725.05 |
| Max. Negotiated Rate |
$8,953.73 |
| Rate for Payer: Aetna Commercial |
$8,759.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,369.80
|
| Rate for Payer: Aetna Managed Medicare |
$2,725.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,326.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,866.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,671.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,158.13
|
| Rate for Payer: Cash Price |
$2,807.40
|
| Rate for Payer: Cigna Commercial |
$8,953.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,446.36
|
| Rate for Payer: Health EOS Commercial |
$8,661.76
|
| Rate for Payer: HFN Commercial |
$8,953.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,299.24
|
| Rate for Payer: Multiplan Commercial |
$7,785.86
|
| Rate for Payer: NAPHCARE Commercial |
$5,839.39
|
| Rate for Payer: Preferred Network Access Commercial |
$8,953.73
|
| Rate for Payer: Quartz Beloit One Network |
$4,768.84
|
| Rate for Payer: Quartz Commercial |
$6,326.01
|
| Rate for Payer: Quartz Medicare Advantage |
$5,839.39
|
| Rate for Payer: The Alliance Commercial |
$4,866.16
|
| Rate for Payer: WEA Trust Commercial |
$5,352.78
|
| Rate for Payer: WPS Commercial |
$7,208.47
|
|
|
ARTICULAR SURFACE CD3-4 14MM PROLONG 5962-30-14
|
Facility
|
IP
|
$9,358.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967577
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,768.84 |
| Max. Negotiated Rate |
$8,953.73 |
| Rate for Payer: Aetna Commercial |
$8,759.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,369.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,158.13
|
| Rate for Payer: Cash Price |
$2,807.40
|
| Rate for Payer: Cigna Commercial |
$8,953.73
|
| Rate for Payer: Health EOS Commercial |
$8,661.76
|
| Rate for Payer: HFN Commercial |
$8,953.73
|
| Rate for Payer: Multiplan Commercial |
$7,785.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,953.73
|
| Rate for Payer: Quartz Beloit One Network |
$4,768.84
|
| Rate for Payer: Quartz Commercial |
$5,839.39
|
| Rate for Payer: WEA Trust Commercial |
$5,352.78
|
| Rate for Payer: WPS Commercial |
$7,208.47
|
|
|
ARTICULAR SURFACE CD 3-4 17MM PROLONG 5962-30-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967578
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 17MM PROLONG 5962-30-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967578
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 20MM PROLONG 5962-30-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967579
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 20MM PROLONG 5962-30-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967579
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 23MM PROLONG 5962-30-23
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967580
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 3-4 23MM PROLONG 5962-30-23
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967580
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 5-6 10MM PROLONG 5962-41-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967581
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 5-6 10MM PROLONG 5962-41-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967581
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 5-6 12MM PROLONG 5962-41-12
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967582
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 5-6 12MM PROLONG 5962-41-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967582
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 5-6 14MM PROLONG 5962-41-14
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967583
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 5-6 14MM PROLONG 5962-41-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967583
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 5-6 17MM PROLONG 5962-41-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE CD 5-6 17MM PROLONG 5962-41-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
