|
ARTICULAR SURFACE PROLONG CR GREEN/C-H 14MM 5952-40-14
|
Facility
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967594
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR GREEN/C-H 17MM 00-5952-40-17
|
Facility
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967595
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR GREEN/C-H 17MM 00-5952-40-17
|
Facility
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967595
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR GREEN/C-H 20MM 90-5952-40-20
|
Facility
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR GREEN/C-H 20MM 90-5952-40-20
|
Facility
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/C-H 10MM 5952-30-10
|
Facility
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967587
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/C-H 10MM 5952-30-10
|
Facility
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967587
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/CH 12MM 5952-30-12
|
Facility
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967588
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/CH 12MM 5952-30-12
|
Facility
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967588
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/C-H 14MM 5952-030-14
|
Facility
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967589
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/C-H 14MM 5952-030-14
|
Facility
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967589
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/C-H 17MM 00-5952-30-17
|
Facility
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967590
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/C-H 17MM 00-5952-30-17
|
Facility
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967590
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/C-H 20MM 00-5952-30-20
|
Facility
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.39 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PROLONG CR YELLOW/C-H 20MM 00-5952-30-20
|
Facility
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.08 |
| Max. Negotiated Rate |
$8,290.12 |
| Rate for Payer: Aetna Commercial |
$8,109.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,749.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,505.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,775.83
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,290.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,042.56
|
| Rate for Payer: Health EOS Commercial |
$8,019.79
|
| Rate for Payer: HFN Commercial |
$8,290.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,758.25
|
| Rate for Payer: Multiplan Commercial |
$7,208.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,406.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,290.12
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.39
|
| Rate for Payer: Quartz Commercial |
$5,857.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,406.60
|
| Rate for Payer: WEA Trust Commercial |
$4,956.05
|
| Rate for Payer: WPS Commercial |
$6,674.45
|
|
|
ARTICULAR SURFACE PSN ASF VE 10-11 EF 16MM L 42-5126-008-16T
|
Facility
OP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,330.04 |
| Max. Negotiated Rate |
$10,941.56 |
| Rate for Payer: Aetna Commercial |
$10,703.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,227.98
|
| Rate for Payer: Aetna Managed Medicare |
$3,330.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,730.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,946.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,708.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,303.29
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$10,941.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,655.32
|
| Rate for Payer: Health EOS Commercial |
$10,584.77
|
| Rate for Payer: HFN Commercial |
$10,941.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,919.75
|
| Rate for Payer: Multiplan Commercial |
$9,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,941.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,827.57
|
| Rate for Payer: Quartz Commercial |
$7,730.45
|
| Rate for Payer: Quartz Medicare Advantage |
$7,135.80
|
| Rate for Payer: WEA Trust Commercial |
$6,541.15
|
| Rate for Payer: WPS Commercial |
$8,809.15
|
|
|
ARTICULAR SURFACE PSN ASF VE 10-11 EF 16MM L 42-5126-008-16T
|
Facility
IP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,827.57 |
| Max. Negotiated Rate |
$10,941.56 |
| Rate for Payer: Aetna Commercial |
$10,703.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,303.29
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$10,941.56
|
| Rate for Payer: Health EOS Commercial |
$10,584.77
|
| Rate for Payer: HFN Commercial |
$10,941.56
|
| Rate for Payer: Multiplan Commercial |
$9,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,941.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,827.57
|
| Rate for Payer: Quartz Commercial |
$7,135.80
|
| Rate for Payer: WEA Trust Commercial |
$6,541.15
|
| Rate for Payer: WPS Commercial |
$8,809.15
|
|
|
ARTICULAR SURFACE PSN ASF VE 6-9 GH 10MM LT 42-5126-009-10
|
Facility
IP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459355
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,827.57 |
| Max. Negotiated Rate |
$10,941.56 |
| Rate for Payer: Aetna Commercial |
$10,703.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,303.29
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$10,941.56
|
| Rate for Payer: Health EOS Commercial |
$10,584.77
|
| Rate for Payer: HFN Commercial |
$10,941.56
|
| Rate for Payer: Multiplan Commercial |
$9,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,941.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,827.57
|
| Rate for Payer: Quartz Commercial |
$7,135.80
|
| Rate for Payer: WEA Trust Commercial |
$6,541.15
|
| Rate for Payer: WPS Commercial |
$8,809.15
|
|
|
ARTICULAR SURFACE PSN ASF VE 6-9 GH 10MM LT 42-5126-009-10
|
Facility
OP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459355
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,330.04 |
| Max. Negotiated Rate |
$10,941.56 |
| Rate for Payer: Aetna Commercial |
$10,703.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,227.98
|
| Rate for Payer: Aetna Managed Medicare |
$3,330.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,730.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,946.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,708.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,303.29
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$10,941.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,655.32
|
| Rate for Payer: Health EOS Commercial |
$10,584.77
|
| Rate for Payer: HFN Commercial |
$10,941.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,919.75
|
| Rate for Payer: Multiplan Commercial |
$9,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,941.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,827.57
|
| Rate for Payer: Quartz Commercial |
$7,730.45
|
| Rate for Payer: Quartz Medicare Advantage |
$7,135.80
|
| Rate for Payer: WEA Trust Commercial |
$6,541.15
|
| Rate for Payer: WPS Commercial |
$8,809.15
|
|
|
ARTICULAR SURFACE PSN CPS VE 3-5 EF 12MM L 42-5126-006-12
|
Facility
IP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106961
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,827.57 |
| Max. Negotiated Rate |
$10,941.56 |
| Rate for Payer: Aetna Commercial |
$10,703.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,303.29
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$10,941.56
|
| Rate for Payer: Health EOS Commercial |
$10,584.77
|
| Rate for Payer: HFN Commercial |
$10,941.56
|
| Rate for Payer: Multiplan Commercial |
$9,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,941.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,827.57
|
| Rate for Payer: Quartz Commercial |
$7,135.80
|
| Rate for Payer: WEA Trust Commercial |
$6,541.15
|
| Rate for Payer: WPS Commercial |
$8,809.15
|
|
|
ARTICULAR SURFACE PSN CPS VE 3-5 EF 12MM L 42-5126-006-12
|
Facility
OP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106961
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,330.04 |
| Max. Negotiated Rate |
$10,941.56 |
| Rate for Payer: Aetna Commercial |
$10,703.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,227.98
|
| Rate for Payer: Aetna Managed Medicare |
$3,330.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,730.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,946.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,708.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,303.29
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$10,941.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,655.32
|
| Rate for Payer: Health EOS Commercial |
$10,584.77
|
| Rate for Payer: HFN Commercial |
$10,941.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,919.75
|
| Rate for Payer: Multiplan Commercial |
$9,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,941.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,827.57
|
| Rate for Payer: Quartz Commercial |
$7,730.45
|
| Rate for Payer: Quartz Medicare Advantage |
$7,135.80
|
| Rate for Payer: WEA Trust Commercial |
$6,541.15
|
| Rate for Payer: WPS Commercial |
$8,809.15
|
|
|
ARTICULAR SURFACE PSN CPS VE 6-9 EF 12MM L 42-5126-007-12
|
Facility
OP
|
$6,656.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,863.68 |
| Max. Negotiated Rate |
$6,123.52 |
| Rate for Payer: Aetna Commercial |
$5,990.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,724.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,863.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,326.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,328.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,194.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,527.68
|
| Rate for Payer: Cash Price |
$1,996.80
|
| Rate for Payer: Cigna Commercial |
$6,123.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,724.70
|
| Rate for Payer: Health EOS Commercial |
$5,923.84
|
| Rate for Payer: HFN Commercial |
$6,123.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,992.00
|
| Rate for Payer: Multiplan Commercial |
$5,324.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,993.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,123.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,261.44
|
| Rate for Payer: Quartz Commercial |
$4,326.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,993.60
|
| Rate for Payer: WEA Trust Commercial |
$3,660.80
|
| Rate for Payer: WPS Commercial |
$4,930.10
|
|
|
ARTICULAR SURFACE PSN CPS VE 6-9 EF 12MM L 42-5126-007-12
|
Facility
IP
|
$6,656.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,261.44 |
| Max. Negotiated Rate |
$6,123.52 |
| Rate for Payer: Aetna Commercial |
$5,990.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,527.68
|
| Rate for Payer: Cash Price |
$1,996.80
|
| Rate for Payer: Cigna Commercial |
$6,123.52
|
| Rate for Payer: Health EOS Commercial |
$5,923.84
|
| Rate for Payer: HFN Commercial |
$6,123.52
|
| Rate for Payer: Multiplan Commercial |
$5,324.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,993.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,123.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,261.44
|
| Rate for Payer: Quartz Commercial |
$3,993.60
|
| Rate for Payer: WEA Trust Commercial |
$3,660.80
|
| Rate for Payer: WPS Commercial |
$4,930.10
|
|
|
ARTICULAR SURFACE PSN PS GH 10-12 11MM L 42-5124-010-11
|
Facility
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3781354
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,297.79 |
| Max. Negotiated Rate |
$8,069.32 |
| Rate for Payer: Aetna Commercial |
$7,893.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,648.63
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,069.32
|
| Rate for Payer: Health EOS Commercial |
$7,806.19
|
| Rate for Payer: HFN Commercial |
$8,069.32
|
| Rate for Payer: Multiplan Commercial |
$7,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,262.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,069.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,297.79
|
| Rate for Payer: Quartz Commercial |
$5,262.60
|
| Rate for Payer: WEA Trust Commercial |
$4,824.05
|
| Rate for Payer: WPS Commercial |
$6,496.68
|
|
|
ARTICULAR SURFACE PSN PS GH 10-12 11MM L 42-5124-010-11
|
Facility
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3781354
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,455.88 |
| Max. Negotiated Rate |
$8,069.32 |
| Rate for Payer: Aetna Commercial |
$7,893.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,543.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,455.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,701.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,385.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,210.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,648.63
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,069.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,908.25
|
| Rate for Payer: Health EOS Commercial |
$7,806.19
|
| Rate for Payer: HFN Commercial |
$8,069.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,578.25
|
| Rate for Payer: Multiplan Commercial |
$7,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,262.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,069.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,297.79
|
| Rate for Payer: Quartz Commercial |
$5,701.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,262.60
|
| Rate for Payer: WEA Trust Commercial |
$4,824.05
|
| Rate for Payer: WPS Commercial |
$6,496.68
|
|
