|
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
|
|
|
ARTICULAR SURFACE PERSONA VE EF 3-5 11MM RT 42-5224-006-11
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962688
|
|
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 EF 3-5 11MM RT 42-5224-006-11
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962688
|
|
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 EF 3-5 12MM RT 42-5224-006-12
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962689
|
|
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 EF 3-5 12MM RT 42-5224-006-12
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962689
|
|
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 EF 3-5 13MM RT 42-5224-006-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962690
|
|
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 EF 3-5 13MM RT 42-5224-006-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962690
|
|
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 EF 3-5 14MM RT 42-5224-006-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962691
|
|
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 EF 3-5 14MM RT 42-5224-006-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962691
|
|
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 EF 3-5 16MM RT 42-5224-006-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962692
|
|
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 EF 3-5 16MM RT 42-5224-006-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962692
|
|
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 EF 3-5 18MM RT 42-5224-006-18
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962693
|
|
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 EF 3-5 18MM RT 42-5224-006-18
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962693
|
|
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 EF 3-5 20MM RT 42-5224-006-20
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962694
|
|
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 EF 3-5 20MM RT 42-5224-006-20
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3962694
|
|
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 PROLONG CR BLUE/C-H 12MM 5952-50-12
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967598
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 12MM 5952-50-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967598
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 14MM 5952-50-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967599
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 14MM 5952-50-14
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967599
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 17MM 5952-50-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967600
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 17MM 5952-50-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967600
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 20MM 5952-50-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967601
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 20MM 5952-50-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967601
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 5952-50-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967597
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,624.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,091.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,685.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,498.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,244.40
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,028.58
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: NAPHCARE Commercial |
$5,622.86
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$6,091.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5,622.86
|
| Rate for Payer: The Alliance Commercial |
$4,685.72
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
|
ARTICULAR SURFACE PROLONG CR BLUE/C-H 5952-50-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967597
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| Max. Negotiated Rate |
$8,621.72 |
| Rate for Payer: Aetna Commercial |
$8,434.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,059.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,966.86
|
| Rate for Payer: Cash Price |
$2,703.30
|
| Rate for Payer: Cigna Commercial |
$8,621.72
|
| Rate for Payer: Health EOS Commercial |
$8,340.58
|
| Rate for Payer: HFN Commercial |
$8,621.72
|
| Rate for Payer: Multiplan Commercial |
$7,497.15
|
| Rate for Payer: Preferred Network Access Commercial |
$8,621.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,592.01
|
| Rate for Payer: Quartz Commercial |
$5,622.86
|
| Rate for Payer: WEA Trust Commercial |
$5,154.29
|
| Rate for Payer: WPS Commercial |
$6,941.17
|
|
