|
ARTICULAR SURFACE YELLOW CD 14MM LCCK 5994-30-14
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973980
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW CD 14MM LCCK 5994-30-14
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973980
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW CD 17MM LCCK 5994-30-17
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967447
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW CD 17MM LCCK 5994-30-17
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967447
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW EF 10MM LCCK 5994-32-10
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973983
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW EF 10MM LCCK 5994-32-10
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973983
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW EF 12MM LCCK 5994-32-12
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW EF 12MM LCCK 5994-32-12
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW EF 14MM LCCK 5994-32-14
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW EF 14MM LCCK 5994-32-14
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2973996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW EF 17MM LCCK 5994-32-17
|
Facility
|
OP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2974007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Aetna Managed Medicare |
$3,013.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,995.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,380.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,165.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,022.54
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,071.44
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: NAPHCARE Commercial |
$6,457.15
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,995.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,457.15
|
| Rate for Payer: The Alliance Commercial |
$5,380.96
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULAR SURFACE YELLOW EF 17MM LCCK 5994-32-17
|
Facility
|
IP
|
$10,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2974007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.34 |
| Max. Negotiated Rate |
$9,900.97 |
| Rate for Payer: Aetna Commercial |
$9,685.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,255.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,703.82
|
| Rate for Payer: Cash Price |
$3,104.40
|
| Rate for Payer: Cigna Commercial |
$9,900.97
|
| Rate for Payer: Health EOS Commercial |
$9,578.11
|
| Rate for Payer: HFN Commercial |
$9,900.97
|
| Rate for Payer: Multiplan Commercial |
$8,609.54
|
| Rate for Payer: Preferred Network Access Commercial |
$9,900.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,273.34
|
| Rate for Payer: Quartz Commercial |
$6,457.15
|
| Rate for Payer: WEA Trust Commercial |
$5,919.06
|
| Rate for Payer: WPS Commercial |
$7,971.06
|
|
|
ARTICULATE SURFACE 5-6/13MM PS 71453223
|
Facility
|
IP
|
$13,706.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3072569
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,984.58 |
| Max. Negotiated Rate |
$13,113.90 |
| Rate for Payer: Aetna Commercial |
$12,828.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,258.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,554.75
|
| Rate for Payer: Cash Price |
$4,111.80
|
| Rate for Payer: Cigna Commercial |
$13,113.90
|
| Rate for Payer: Health EOS Commercial |
$12,686.27
|
| Rate for Payer: HFN Commercial |
$13,113.90
|
| Rate for Payer: Multiplan Commercial |
$11,403.39
|
| Rate for Payer: Preferred Network Access Commercial |
$13,113.90
|
| Rate for Payer: Quartz Beloit One Network |
$6,984.58
|
| Rate for Payer: Quartz Commercial |
$8,552.54
|
| Rate for Payer: WEA Trust Commercial |
$7,839.83
|
| Rate for Payer: WPS Commercial |
$10,557.73
|
|
|
ARTICULATE SURFACE 5-6/13MM PS 71453223
|
Facility
|
OP
|
$13,706.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3072569
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,991.19 |
| Max. Negotiated Rate |
$13,113.90 |
| Rate for Payer: Aetna Commercial |
$12,828.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,258.65
|
| Rate for Payer: Aetna Managed Medicare |
$3,991.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,265.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,127.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,842.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,554.75
|
| Rate for Payer: Cash Price |
$4,111.80
|
| Rate for Payer: Cigna Commercial |
$13,113.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,976.89
|
| Rate for Payer: Health EOS Commercial |
$12,686.27
|
| Rate for Payer: HFN Commercial |
$13,113.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,690.68
|
| Rate for Payer: Multiplan Commercial |
$11,403.39
|
| Rate for Payer: NAPHCARE Commercial |
$8,552.54
|
| Rate for Payer: Preferred Network Access Commercial |
$13,113.90
|
| Rate for Payer: Quartz Beloit One Network |
$6,984.58
|
| Rate for Payer: Quartz Commercial |
$9,265.26
|
| Rate for Payer: Quartz Medicare Advantage |
$8,552.54
|
| Rate for Payer: The Alliance Commercial |
$7,127.12
|
| Rate for Payer: WEA Trust Commercial |
$7,839.83
|
| Rate for Payer: WPS Commercial |
$10,557.73
|
|
|
ARTICULATE SURFACE PROLONG GH 5-6 14MM 5962-42-14
|
Facility
|
IP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967622
|
|
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
|
|
|
ARTICULATE SURFACE PROLONG GH 5-6 14MM 5962-42-14
|
Facility
|
OP
|
$9,011.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967622
|
|
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
|
|
|
ARTICULATE SURFACE PSN CR VE 11MM 3-11 EF LT 42-5120-005-11
|
Facility
|
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4106951
|
|
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
|
|
|
ARTICULATE SURFACE PSN CR VE 11MM 3-11 EF LT 42-5120-005-11
|
Facility
|
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4106951
|
|
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
|
|
|
ARTICULATE SURFACE ROTATING HINGE NEXGEN SZ D 17MM 00-5880-040-17
|
Facility
|
IP
|
$9,179.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,677.62 |
| Max. Negotiated Rate |
$8,782.47 |
| Rate for Payer: Aetna Commercial |
$8,591.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,209.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,059.46
|
| Rate for Payer: Cash Price |
$2,753.70
|
| Rate for Payer: Cigna Commercial |
$8,782.47
|
| Rate for Payer: Health EOS Commercial |
$8,496.08
|
| Rate for Payer: HFN Commercial |
$8,782.47
|
| Rate for Payer: Multiplan Commercial |
$7,636.93
|
| Rate for Payer: Preferred Network Access Commercial |
$8,782.47
|
| Rate for Payer: Quartz Beloit One Network |
$4,677.62
|
| Rate for Payer: Quartz Commercial |
$5,727.70
|
| Rate for Payer: WEA Trust Commercial |
$5,250.39
|
| Rate for Payer: WPS Commercial |
$7,070.58
|
|
|
ARTICULATE SURFACE ROTATING HINGE NEXGEN SZ D 17MM 00-5880-040-17
|
Facility
|
OP
|
$9,179.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,672.92 |
| Max. Negotiated Rate |
$8,782.47 |
| Rate for Payer: Aetna Commercial |
$8,591.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,209.70
|
| Rate for Payer: Aetna Managed Medicare |
$2,672.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,773.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,582.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,059.46
|
| Rate for Payer: Cash Price |
$2,753.70
|
| Rate for Payer: Cigna Commercial |
$8,782.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,342.18
|
| Rate for Payer: Health EOS Commercial |
$8,496.08
|
| Rate for Payer: HFN Commercial |
$8,782.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,159.62
|
| Rate for Payer: Multiplan Commercial |
$7,636.93
|
| Rate for Payer: NAPHCARE Commercial |
$5,727.70
|
| Rate for Payer: Preferred Network Access Commercial |
$8,782.47
|
| Rate for Payer: Quartz Beloit One Network |
$4,677.62
|
| Rate for Payer: Quartz Commercial |
$6,205.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5,727.70
|
| Rate for Payer: The Alliance Commercial |
$4,773.08
|
| Rate for Payer: WEA Trust Commercial |
$5,250.39
|
| Rate for Payer: WPS Commercial |
$7,070.58
|
|
|
ART LINE INSERT SAMPLING/MONITORING/TRANSFUSION
|
Facility
|
OP
|
$648.00
|
|
|
Service Code
|
CPT 36620
|
| Hospital Charge Code |
5464767
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$160.91 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$606.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$579.57
|
| Rate for Payer: Aetna Managed Medicare |
$188.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$438.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$336.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$323.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$357.18
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cigna Commercial |
$620.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$599.79
|
| Rate for Payer: HFN Commercial |
$620.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$505.44
|
| Rate for Payer: Multiplan Commercial |
$539.14
|
| Rate for Payer: NAPHCARE Commercial |
$404.35
|
| Rate for Payer: Preferred Network Access Commercial |
$620.01
|
| Rate for Payer: Quartz Beloit One Network |
$330.22
|
| Rate for Payer: Quartz Commercial |
$438.05
|
| Rate for Payer: Quartz Medicare Advantage |
$404.35
|
| Rate for Payer: The Alliance Commercial |
$160.91
|
| Rate for Payer: WEA Trust Commercial |
$370.66
|
| Rate for Payer: WPS Commercial |
$499.15
|
|
|
ART LINE INSERT SAMPLING/MONITORING/TRANSFUSION
|
Facility
|
IP
|
$648.00
|
|
|
Service Code
|
CPT 36620
|
| Hospital Charge Code |
5464767
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$330.22 |
| Max. Negotiated Rate |
$620.01 |
| Rate for Payer: Aetna Commercial |
$606.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$579.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$357.18
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cigna Commercial |
$620.01
|
| Rate for Payer: Health EOS Commercial |
$599.79
|
| Rate for Payer: HFN Commercial |
$620.01
|
| Rate for Payer: Multiplan Commercial |
$539.14
|
| Rate for Payer: Preferred Network Access Commercial |
$620.01
|
| Rate for Payer: Quartz Beloit One Network |
$330.22
|
| Rate for Payer: Quartz Commercial |
$404.35
|
| Rate for Payer: WEA Trust Commercial |
$370.66
|
| Rate for Payer: WPS Commercial |
$499.15
|
|
|
ART SURFACE CD/3-4 10MM 5994-30-10
|
Facility
|
IP
|
$10,062.00
|
|
| Hospital Charge Code |
2969427
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,127.60 |
| Max. Negotiated Rate |
$9,627.32 |
| Rate for Payer: Aetna Commercial |
$9,418.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,999.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,546.17
|
| Rate for Payer: Cash Price |
$3,018.60
|
| Rate for Payer: Cigna Commercial |
$9,627.32
|
| Rate for Payer: Health EOS Commercial |
$9,313.39
|
| Rate for Payer: HFN Commercial |
$9,627.32
|
| Rate for Payer: Multiplan Commercial |
$8,371.58
|
| Rate for Payer: Preferred Network Access Commercial |
$9,627.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,127.60
|
| Rate for Payer: Quartz Commercial |
$6,278.69
|
| Rate for Payer: WEA Trust Commercial |
$5,755.46
|
| Rate for Payer: WPS Commercial |
$7,750.76
|
|
|
ART SURFACE CD/3-4 10MM 5994-30-10
|
Facility
|
OP
|
$10,062.00
|
|
| Hospital Charge Code |
2969427
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,930.05 |
| Max. Negotiated Rate |
$9,627.32 |
| Rate for Payer: Aetna Commercial |
$9,418.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,999.45
|
| Rate for Payer: Aetna Managed Medicare |
$2,930.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,801.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,232.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,022.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,546.17
|
| Rate for Payer: Cash Price |
$3,018.60
|
| Rate for Payer: Cigna Commercial |
$9,627.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,856.08
|
| Rate for Payer: Health EOS Commercial |
$9,313.39
|
| Rate for Payer: HFN Commercial |
$9,627.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,848.36
|
| Rate for Payer: Multiplan Commercial |
$8,371.58
|
| Rate for Payer: NAPHCARE Commercial |
$6,278.69
|
| Rate for Payer: Preferred Network Access Commercial |
$9,627.32
|
| Rate for Payer: Quartz Beloit One Network |
$5,127.60
|
| Rate for Payer: Quartz Commercial |
$6,801.91
|
| Rate for Payer: Quartz Medicare Advantage |
$6,278.69
|
| Rate for Payer: The Alliance Commercial |
$5,232.24
|
| Rate for Payer: WEA Trust Commercial |
$5,755.46
|
| Rate for Payer: WPS Commercial |
$7,750.76
|
|
|
ART SURFACE PSN CR VE 3-11 EF 14MM RT 42-5220-005-14
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
4641025
|
|
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
|
|
