|
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 |
$4,592.01 |
| 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 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 |
$2,624.00 |
| 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 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 |
$4,592.01 |
| 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 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 |
$2,624.00 |
| 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 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 |
$2,624.00 |
| 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 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 |
$4,592.01 |
| 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 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 |
$2,624.00 |
| 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 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 |
$4,592.01 |
| 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 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 |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
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 |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
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 |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN EF 12MM LCCK 5994-40-12
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973985
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN EF 14MM LCCK 5994-40-14
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973997
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN EF 14MM LCCK 5994-40-14
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973997
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN EF 17MM LCCK 5994-40-17
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2974000
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN EF 17MM LCCK 5994-40-17
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2974000
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN SZ G 10MM LCCK 5994-42-10
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN SZ G 10MM LCCK 5994-42-10
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN SZ G 12MM LCCK 5994-42-12
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973987
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN SZ G 12MM LCCK 5994-42-12
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973987
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN SZ G 14MM LCCK 5994-42-14
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN SZ G 14MM LCCK 5994-42-14
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN SZ G 17MM LCCK 5994-42-17
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973989
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE GREEN SZ G 17MM LCCK 5994-42-17
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973989
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE LPS FLEX EF 3-4 12MM 5962-32-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967603
|
|
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
|
|
