|
ARTICULAR SURFACE PERSONA VE 4-11 E-F RIGHT 14MM 42-5222-005-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4028635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 4-11 E-F RIGHT 16MM 42-5222-005-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4264795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 4-11 E-F RIGHT 16MM 42-5222-005-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4264795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 4-11 E-F RIGHT 18MM 42-5222-005-18
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 4-11 E-F RIGHT 18MM 42-5222-005-18
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 4-11 E-F RIGHT 20MM 42-5222-005-20
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 4-11 E-F RIGHT 20MM 42-5222-005-20
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 10MM 42-5122-006-10
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072611
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 10MM 42-5122-006-10
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072611
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 11MM 42-5122-006-11
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 11MM 42-5122-006-11
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 12MM 42-5122-006-12
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4450334
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 12MM 42-5122-006-12
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4450334
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 13MM 42-5122-006-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 13MM 42-5122-006-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072613
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 14MM 42-5122-006-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072614
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 G-H LEFT 14MM 42-5122-006-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072614
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 GH RT 10MM 42-5222-006-10
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3937330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 GH RT 10MM 42-5222-006-10
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3937330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 GH RT 11MM 42-5222-006-11
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4594658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 GH RT 11MM 42-5222-006-11
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4594658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 GH RT 12MM 42-5222-006-12
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3901352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 GH RT 12MM 42-5222-006-12
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3901352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 GH RT 13MM 42-5222-006-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ARTICULAR SURFACE PERSONA VE 7-12 GH RT 13MM 42-5222-006-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5072619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
