|
ARTICULAR SURFACE PERSONA VE CD 6-9 14MM RT 42-5224-005-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3922774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CD 6-9 14MM RT 42-5224-005-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3922774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CD 6-9 16MM RT 42-5224-005-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CD 6-9 16MM RT 42-5224-005-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CD 6-9 18MM RT 42-5224-005-18
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CD 6-9 18MM RT 42-5224-005-18
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CD 6-9 20MM RT 42-5224-005-20
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CD 6-9 20MM RT 42-5224-005-20
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CR 11MM 3-9 CD LEFT 42-5120-004-11
|
Facility
|
IP
|
$8,903.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4202656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,536.97 |
| Max. Negotiated Rate |
$8,518.39 |
| Rate for Payer: Aetna Commercial |
$8,333.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,962.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,907.33
|
| Rate for Payer: Cash Price |
$2,670.90
|
| Rate for Payer: Cigna Commercial |
$8,518.39
|
| Rate for Payer: Health EOS Commercial |
$8,240.62
|
| Rate for Payer: HFN Commercial |
$8,518.39
|
| Rate for Payer: Multiplan Commercial |
$7,407.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,518.39
|
| Rate for Payer: Quartz Beloit One Network |
$4,536.97
|
| Rate for Payer: Quartz Commercial |
$5,555.47
|
| Rate for Payer: WEA Trust Commercial |
$5,092.52
|
| Rate for Payer: WPS Commercial |
$6,857.98
|
|
|
ARTICULAR SURFACE PERSONA VE CR 11MM 3-9 CD LEFT 42-5120-004-11
|
Facility
|
OP
|
$8,903.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4202656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,592.55 |
| Max. Negotiated Rate |
$8,518.39 |
| Rate for Payer: Aetna Commercial |
$8,333.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,962.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,592.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,018.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,629.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,444.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,907.33
|
| Rate for Payer: Cash Price |
$2,670.90
|
| Rate for Payer: Cigna Commercial |
$8,518.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,181.55
|
| Rate for Payer: Health EOS Commercial |
$8,240.62
|
| Rate for Payer: HFN Commercial |
$8,518.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,944.34
|
| Rate for Payer: Multiplan Commercial |
$7,407.30
|
| Rate for Payer: NAPHCARE Commercial |
$5,555.47
|
| Rate for Payer: Preferred Network Access Commercial |
$8,518.39
|
| Rate for Payer: Quartz Beloit One Network |
$4,536.97
|
| Rate for Payer: Quartz Commercial |
$6,018.43
|
| Rate for Payer: Quartz Medicare Advantage |
$5,555.47
|
| Rate for Payer: The Alliance Commercial |
$4,629.56
|
| Rate for Payer: WEA Trust Commercial |
$5,092.52
|
| Rate for Payer: WPS Commercial |
$6,857.98
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-11 EF 12MM LEFT 42-5120-005-12
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493835
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,469.70 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,473.10
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-11 EF 12MM LEFT 42-5120-005-12
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4493835
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,554.12 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,554.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,929.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,560.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,378.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,104.72
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,841.38
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: NAPHCARE Commercial |
$5,473.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,929.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,473.10
|
| Rate for Payer: The Alliance Commercial |
$4,560.92
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-11 EF 13MM LEFT 42-5120-005-13
|
Facility
|
OP
|
$8,121.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.84 |
| Max. Negotiated Rate |
$7,770.17 |
| Rate for Payer: Aetna Commercial |
$7,601.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,222.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.30
|
| Rate for Payer: Cash Price |
$2,436.30
|
| Rate for Payer: Cigna Commercial |
$7,770.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.42
|
| Rate for Payer: Health EOS Commercial |
$7,516.80
|
| Rate for Payer: HFN Commercial |
$7,770.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.38
|
| Rate for Payer: Multiplan Commercial |
$6,756.67
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.50
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.17
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.46
|
| Rate for Payer: Quartz Commercial |
$5,489.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.50
|
| Rate for Payer: The Alliance Commercial |
$4,222.92
|
| Rate for Payer: WEA Trust Commercial |
$4,645.21
|
| Rate for Payer: WPS Commercial |
$6,255.61
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-11 EF 13MM LEFT 42-5120-005-13
|
Facility
|
IP
|
$8,121.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.46 |
| Max. Negotiated Rate |
$7,770.17 |
| Rate for Payer: Aetna Commercial |
$7,601.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.30
|
| Rate for Payer: Cash Price |
$2,436.30
|
| Rate for Payer: Cigna Commercial |
$7,770.17
|
| Rate for Payer: Health EOS Commercial |
$7,516.80
|
| Rate for Payer: HFN Commercial |
$7,770.17
|
| Rate for Payer: Multiplan Commercial |
$6,756.67
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.17
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.46
|
| Rate for Payer: Quartz Commercial |
$5,067.50
|
| Rate for Payer: WEA Trust Commercial |
$4,645.21
|
| Rate for Payer: WPS Commercial |
$6,255.61
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-11 EF 14MM LEFT 42-5120-005-14
|
Facility
|
IP
|
$8,121.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4595342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.46 |
| Max. Negotiated Rate |
$7,770.17 |
| Rate for Payer: Aetna Commercial |
$7,601.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.30
|
| Rate for Payer: Cash Price |
$2,436.30
|
| Rate for Payer: Cigna Commercial |
$7,770.17
|
| Rate for Payer: Health EOS Commercial |
$7,516.80
|
| Rate for Payer: HFN Commercial |
$7,770.17
|
| Rate for Payer: Multiplan Commercial |
$6,756.67
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.17
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.46
|
| Rate for Payer: Quartz Commercial |
$5,067.50
|
| Rate for Payer: WEA Trust Commercial |
$4,645.21
|
| Rate for Payer: WPS Commercial |
$6,255.61
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-11 EF 14MM LEFT 42-5120-005-14
|
Facility
|
OP
|
$8,121.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4595342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.84 |
| Max. Negotiated Rate |
$7,770.17 |
| Rate for Payer: Aetna Commercial |
$7,601.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,222.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.30
|
| Rate for Payer: Cash Price |
$2,436.30
|
| Rate for Payer: Cigna Commercial |
$7,770.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.42
|
| Rate for Payer: Health EOS Commercial |
$7,516.80
|
| Rate for Payer: HFN Commercial |
$7,770.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.38
|
| Rate for Payer: Multiplan Commercial |
$6,756.67
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.50
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.17
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.46
|
| Rate for Payer: Quartz Commercial |
$5,489.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.50
|
| Rate for Payer: The Alliance Commercial |
$4,222.92
|
| Rate for Payer: WEA Trust Commercial |
$4,645.21
|
| Rate for Payer: WPS Commercial |
$6,255.61
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-9 CD 12MM LEFT 42-5120-004-12
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-9 CD 12MM LEFT 42-5120-004-12
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3529502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-9 CD 13MM LEFT 42-5120-004-13
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4434531
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,469.70 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,473.10
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ARTICULAR SURFACE PERSONA VE CR 3-9 CD 13MM LEFT 42-5120-004-13
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4434531
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,554.12 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,554.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,929.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,560.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,378.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,104.72
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,841.38
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: NAPHCARE Commercial |
$5,473.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,929.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,473.10
|
| Rate for Payer: The Alliance Commercial |
$4,560.92
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ARTICULAR SURFACE PERSONA VE EF 10-11 10MM RT 42-5224-008-10
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3784172
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,469.70 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,473.10
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ARTICULAR SURFACE PERSONA VE EF 10-11 10MM RT 42-5224-008-10
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3784172
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,554.12 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,554.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,929.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,560.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,378.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,104.72
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,841.38
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: NAPHCARE Commercial |
$5,473.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,929.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,473.10
|
| Rate for Payer: The Alliance Commercial |
$4,560.92
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ARTICULAR SURFACE PERSONA VE EF 10-11 11MM RT 42-5224-008-11
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,554.12 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,554.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,929.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,560.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,378.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,104.72
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,841.38
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: NAPHCARE Commercial |
$5,473.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,929.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,473.10
|
| Rate for Payer: The Alliance Commercial |
$4,560.92
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ARTICULAR SURFACE PERSONA VE EF 10-11 11MM RT 42-5224-008-11
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,469.70 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,473.10
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
ARTICULAR SURFACE PERSONA VE EF 3-5 10MM RT 42-5224-006-10
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
