|
ARTICULAR SURFACE PSN PS VE 12MM 3-5 CD LT 42-5124-004-12
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953316
|
|
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 PSN PS VE 12MM L 10-11 EF 42-5124-008-12
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3937328
|
|
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 PSN PS VE 12MM L 10-11 EF 42-5124-008-12
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3937328
|
|
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 PSN PS VE 12MM L 6-9 GH 42-5124-009-12
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953347
|
|
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 PSN PS VE 12MM L 6-9 GH 42-5124-009-12
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953347
|
|
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 PSN PS VE 13MM 3-5 CD LT 42-5124-004-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953317
|
|
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 PSN PS VE 13MM 3-5 CD LT 42-5124-004-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953317
|
|
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 PSN PS VE 13MM L 10-11 EF 42-5124-008-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953340
|
|
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 PSN PS VE 13MM L 10-11 EF 42-5124-008-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953340
|
|
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 PSN PS VE 13MM L 6-9 GH 42-5124-009-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953348
|
|
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 PSN PS VE 13MM L 6-9 GH 42-5124-009-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953348
|
|
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 PSN PS VE 14MM 3-5 CD LT 42-5124-004-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953318
|
|
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 PSN PS VE 14MM 3-5 CD LT 42-5124-004-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953318
|
|
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 PSN PS VE 14MM L 10-11 EF 42-5124-008-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953341
|
|
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 PSN PS VE 14MM L 10-11 EF 42-5124-008-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953341
|
|
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 PSN PS VE 14MM L 6-9 GH 42-5124-009-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953349
|
|
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 PSN PS VE 14MM L 6-9 GH 42-5124-009-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953349
|
|
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 PSN PS VE 16MM 3-5 CD LT 42-5124-004-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953319
|
|
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 PSN PS VE 16MM 3-5 CD LT 42-5124-004-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953319
|
|
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 PSN PS VE 16MM L 10-11 EF 42-5124-008-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953342
|
|
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 PSN PS VE 16MM L 10-11 EF 42-5124-008-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953342
|
|
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 PSN PS VE 16MM L 6-9 GH 42-5124-009-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953350
|
|
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 PSN PS VE 16MM L 6-9 GH 42-5124-009-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953350
|
|
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 PSN PS VE 18MM 3-5 CD LT 42-5124-004-18
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953320
|
|
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 PSN PS VE 18MM 3-5 CD LT 42-5124-004-18
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953320
|
|
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
|
|
