|
ARTICULAR SURFACE PROLONG CR GREEN/C-H 10MM 5952-040-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967592
|
|
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 GREEN/C-H 10MM 5952-040-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967592
|
|
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 GREEN/C-H 12MM 5952-40-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967593
|
|
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 GREEN/C-H 12MM 5952-40-12
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967593
|
|
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 GREEN/C-H 14MM 5952-40-14
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967594
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| 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 GREEN/C-H 14MM 5952-40-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967594
|
|
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 GREEN/C-H 17MM 00-5952-40-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967595
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| 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 GREEN/C-H 17MM 00-5952-40-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967595
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| 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 GREEN/C-H 20MM 90-5952-40-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| 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 GREEN/C-H 20MM 90-5952-40-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| 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 YELLOW/C-H 10MM 5952-30-10
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967587
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| 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 YELLOW/C-H 10MM 5952-30-10
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967587
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| 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 YELLOW/CH 12MM 5952-30-12
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967588
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| 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 YELLOW/CH 12MM 5952-30-12
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967588
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| 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 YELLOW/C-H 14MM 5952-030-14
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967589
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| 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 YELLOW/C-H 14MM 5952-030-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967589
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| 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 YELLOW/C-H 17MM 00-5952-30-17
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967590
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| 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 YELLOW/C-H 17MM 00-5952-30-17
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967590
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| 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 YELLOW/C-H 20MM 00-5952-30-20
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,592.01 |
| 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 YELLOW/C-H 20MM 00-5952-30-20
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| 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 PSN ASF VE 10-11 EF 16MM L 42-5126-008-16T
|
Facility
|
IP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,060.67 |
| Max. Negotiated Rate |
$11,379.22 |
| Rate for Payer: Aetna Commercial |
$11,131.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,637.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,555.42
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$11,379.22
|
| Rate for Payer: Health EOS Commercial |
$11,008.16
|
| Rate for Payer: HFN Commercial |
$11,379.22
|
| Rate for Payer: Multiplan Commercial |
$9,894.98
|
| Rate for Payer: Preferred Network Access Commercial |
$11,379.22
|
| Rate for Payer: Quartz Beloit One Network |
$6,060.67
|
| Rate for Payer: Quartz Commercial |
$7,421.23
|
| Rate for Payer: WEA Trust Commercial |
$6,802.80
|
| Rate for Payer: WPS Commercial |
$9,161.18
|
|
|
ARTICULAR SURFACE PSN ASF VE 10-11 EF 16MM L 42-5126-008-16T
|
Facility
|
OP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,463.24 |
| Max. Negotiated Rate |
$11,379.22 |
| Rate for Payer: Aetna Commercial |
$11,131.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,637.10
|
| Rate for Payer: Aetna Managed Medicare |
$3,463.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,039.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,184.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,936.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,555.42
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$11,379.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,921.73
|
| Rate for Payer: Health EOS Commercial |
$11,008.16
|
| Rate for Payer: HFN Commercial |
$11,379.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,276.54
|
| Rate for Payer: Multiplan Commercial |
$9,894.98
|
| Rate for Payer: NAPHCARE Commercial |
$7,421.23
|
| Rate for Payer: Preferred Network Access Commercial |
$11,379.22
|
| Rate for Payer: Quartz Beloit One Network |
$6,060.67
|
| Rate for Payer: Quartz Commercial |
$8,039.67
|
| Rate for Payer: Quartz Medicare Advantage |
$7,421.23
|
| Rate for Payer: The Alliance Commercial |
$6,184.36
|
| Rate for Payer: WEA Trust Commercial |
$6,802.80
|
| Rate for Payer: WPS Commercial |
$9,161.18
|
|
|
ARTICULAR SURFACE PSN ASF VE 6-9 GH 10MM LT 42-5126-009-10
|
Facility
|
IP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459355
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,060.67 |
| Max. Negotiated Rate |
$11,379.22 |
| Rate for Payer: Aetna Commercial |
$11,131.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,637.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,555.42
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$11,379.22
|
| Rate for Payer: Health EOS Commercial |
$11,008.16
|
| Rate for Payer: HFN Commercial |
$11,379.22
|
| Rate for Payer: Multiplan Commercial |
$9,894.98
|
| Rate for Payer: Preferred Network Access Commercial |
$11,379.22
|
| Rate for Payer: Quartz Beloit One Network |
$6,060.67
|
| Rate for Payer: Quartz Commercial |
$7,421.23
|
| Rate for Payer: WEA Trust Commercial |
$6,802.80
|
| Rate for Payer: WPS Commercial |
$9,161.18
|
|
|
ARTICULAR SURFACE PSN ASF VE 6-9 GH 10MM LT 42-5126-009-10
|
Facility
|
OP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459355
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,463.24 |
| Max. Negotiated Rate |
$11,379.22 |
| Rate for Payer: Aetna Commercial |
$11,131.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,637.10
|
| Rate for Payer: Aetna Managed Medicare |
$3,463.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,039.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,184.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,936.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,555.42
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$11,379.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,921.73
|
| Rate for Payer: Health EOS Commercial |
$11,008.16
|
| Rate for Payer: HFN Commercial |
$11,379.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,276.54
|
| Rate for Payer: Multiplan Commercial |
$9,894.98
|
| Rate for Payer: NAPHCARE Commercial |
$7,421.23
|
| Rate for Payer: Preferred Network Access Commercial |
$11,379.22
|
| Rate for Payer: Quartz Beloit One Network |
$6,060.67
|
| Rate for Payer: Quartz Commercial |
$8,039.67
|
| Rate for Payer: Quartz Medicare Advantage |
$7,421.23
|
| Rate for Payer: The Alliance Commercial |
$6,184.36
|
| Rate for Payer: WEA Trust Commercial |
$6,802.80
|
| Rate for Payer: WPS Commercial |
$9,161.18
|
|
|
ARTICULAR SURFACE PSN CPS VE 3-5 EF 12MM L 42-5126-006-12
|
Facility
|
OP
|
$11,893.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106961
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,463.24 |
| Max. Negotiated Rate |
$11,379.22 |
| Rate for Payer: Aetna Commercial |
$11,131.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,637.10
|
| Rate for Payer: Aetna Managed Medicare |
$3,463.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,039.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,184.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,936.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,555.42
|
| Rate for Payer: Cash Price |
$3,567.90
|
| Rate for Payer: Cigna Commercial |
$11,379.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,921.73
|
| Rate for Payer: Health EOS Commercial |
$11,008.16
|
| Rate for Payer: HFN Commercial |
$11,379.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,276.54
|
| Rate for Payer: Multiplan Commercial |
$9,894.98
|
| Rate for Payer: NAPHCARE Commercial |
$7,421.23
|
| Rate for Payer: Preferred Network Access Commercial |
$11,379.22
|
| Rate for Payer: Quartz Beloit One Network |
$6,060.67
|
| Rate for Payer: Quartz Commercial |
$8,039.67
|
| Rate for Payer: Quartz Medicare Advantage |
$7,421.23
|
| Rate for Payer: The Alliance Commercial |
$6,184.36
|
| Rate for Payer: WEA Trust Commercial |
$6,802.80
|
| Rate for Payer: WPS Commercial |
$9,161.18
|
|
