|
ARTICULAR SURFACE PSN PS VE 3-5 EF 12MM L 42-5124-006-12
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953328
|
|
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 PSN PS VE 3-5 EF 12MM L 42-5124-006-12
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953328
|
|
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 PSN PS VE 3-5 EF 13MM L 42-5124-006-13
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953329
|
|
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 PSN PS VE 3-5 EF 13MM L 42-5124-006-13
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953329
|
|
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 PSN PS VE 3-5 EF 14MM L 42-5124-006-14
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953330
|
|
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 PSN PS VE 3-5 EF 14MM L 42-5124-006-14
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953330
|
|
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 PSN PS VE 3-5 EF 16MM L 42-5124-006-16
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953331
|
|
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 PSN PS VE 3-5 EF 16MM L 42-5124-006-16
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953331
|
|
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 PSN PS VE 3-5 EF 18MM L 42-5124-006-18
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953332
|
|
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 PSN PS VE 3-5 EF 18MM L 42-5124-006-18
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953332
|
|
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 PSN PS VE 3-5 EF 20MM L 42-5124-006-20
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953333
|
|
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 PSN PS VE 3-5 EF 20MM L 42-5124-006-20
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953333
|
|
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 PSN PS VE 6-9 CD 13MM L 42-5124-005-13
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583496
|
|
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 PSN PS VE 6-9 CD 13MM L 42-5124-005-13
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583496
|
|
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 PSN PS VE 6-9 CD 14MM L 42-5124-005-14
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953322
|
|
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 PSN PS VE 6-9 CD 14MM L 42-5124-005-14
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953322
|
|
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 PSN PS VE 6-9 CD 16MM L 42-5124-005-16
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953323
|
|
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 PSN PS VE 6-9 CD 16MM L 42-5124-005-16
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953323
|
|
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 PSN PS VE 6-9 CD 18MM L 42-5124-005-18
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953324
|
|
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 PSN PS VE 6-9 CD 18MM L 42-5124-005-18
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953324
|
|
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 PSN PS VE 6-9 CD 20MM L 42-5124-005-20
|
Facility
|
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953325
|
|
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 PSN PS VE 6-9 CD 20MM L 42-5124-005-20
|
Facility
|
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3953325
|
|
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 PSN PS VE 6-9 EF 11MM 42-5124-007-11
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583497
|
|
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 PSN PS VE 6-9 EF 11MM 42-5124-007-11
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583497
|
|
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 PSN PS VE 6-9 EF 12MM 42-5124-007-12
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3337519
|
|
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
|
|
