|
TIBIAL PLATE ROTATING HINGE NEXGEN STEMMED RT SZ 3 00-5880-003-00
|
Facility
|
OP
|
$20,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,805.80 |
| Max. Negotiated Rate |
$82,940.00 |
| Rate for Payer: Aetna Commercial |
$18,661.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,832.10
|
| Rate for Payer: Aetna Managed Medicare |
$5,805.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,477.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,367.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,952.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,989.55
|
| Rate for Payer: Cash Price |
$6,220.50
|
| Rate for Payer: Cigna Commercial |
$19,076.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,603.31
|
| Rate for Payer: Health EOS Commercial |
$18,454.15
|
| Rate for Payer: HFN Commercial |
$19,076.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,551.25
|
| Rate for Payer: Multiplan Commercial |
$16,588.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,441.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,076.20
|
| Rate for Payer: Quartz Beloit One Network |
$10,160.15
|
| Rate for Payer: Quartz Commercial |
$13,477.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,441.00
|
| Rate for Payer: The Alliance Commercial |
$82,940.00
|
| Rate for Payer: WEA Trust Commercial |
$11,404.25
|
| Rate for Payer: WPS Commercial |
$15,358.41
|
|
|
TIBIAL PLATE SIZE 1 MICRO 5980-27-01
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967539
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SIZE 1 MICRO 5980-27-01
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967539
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SIZE 2 MICRO 5980-27-02
|
Facility
|
IP
|
$9,587.00
|
|
| Hospital Charge Code |
2967540
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,697.63 |
| Max. Negotiated Rate |
$8,820.04 |
| Rate for Payer: Aetna Commercial |
$8,628.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,244.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,081.11
|
| Rate for Payer: Cash Price |
$2,876.10
|
| Rate for Payer: Cigna Commercial |
$8,820.04
|
| Rate for Payer: Health EOS Commercial |
$8,532.43
|
| Rate for Payer: HFN Commercial |
$8,820.04
|
| Rate for Payer: Multiplan Commercial |
$7,669.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,752.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,820.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,697.63
|
| Rate for Payer: Quartz Commercial |
$5,752.20
|
| Rate for Payer: WEA Trust Commercial |
$5,272.85
|
| Rate for Payer: WPS Commercial |
$7,101.09
|
|
|
TIBIAL PLATE SIZE 2 MICRO 5980-27-02
|
Facility
|
OP
|
$9,587.00
|
|
| Hospital Charge Code |
2967540
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,684.36 |
| Max. Negotiated Rate |
$38,348.00 |
| Rate for Payer: Aetna Commercial |
$8,628.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,244.82
|
| Rate for Payer: Aetna Managed Medicare |
$2,684.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,231.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,793.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,601.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,081.11
|
| Rate for Payer: Cash Price |
$2,876.10
|
| Rate for Payer: Cigna Commercial |
$8,820.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,364.89
|
| Rate for Payer: Health EOS Commercial |
$8,532.43
|
| Rate for Payer: HFN Commercial |
$8,820.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,190.25
|
| Rate for Payer: Multiplan Commercial |
$7,669.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,752.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,820.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,697.63
|
| Rate for Payer: Quartz Commercial |
$6,231.55
|
| Rate for Payer: Quartz Medicare Advantage |
$5,752.20
|
| Rate for Payer: The Alliance Commercial |
$38,348.00
|
| Rate for Payer: WEA Trust Commercial |
$5,272.85
|
| Rate for Payer: WPS Commercial |
$7,101.09
|
|
|
TIBIAL PLATE SIZE 3 5980-37-01
|
Facility
|
IP
|
$8,170.00
|
|
| Hospital Charge Code |
2967758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,003.30 |
| Max. Negotiated Rate |
$7,516.40 |
| Rate for Payer: Aetna Commercial |
$7,353.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,026.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,330.10
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$7,516.40
|
| Rate for Payer: Health EOS Commercial |
$7,271.30
|
| Rate for Payer: HFN Commercial |
$7,516.40
|
| Rate for Payer: Multiplan Commercial |
$6,536.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,902.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,516.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,003.30
|
| Rate for Payer: Quartz Commercial |
$4,902.00
|
| Rate for Payer: WEA Trust Commercial |
$4,493.50
|
| Rate for Payer: WPS Commercial |
$6,051.52
|
|
|
TIBIAL PLATE SIZE 3 5980-37-01
|
Facility
|
OP
|
$8,170.00
|
|
| Hospital Charge Code |
2967758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,287.60 |
| Max. Negotiated Rate |
$32,680.00 |
| Rate for Payer: Aetna Commercial |
$7,353.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,026.20
|
| Rate for Payer: Aetna Managed Medicare |
$2,287.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,310.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,330.10
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$7,516.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,571.93
|
| Rate for Payer: Health EOS Commercial |
$7,271.30
|
| Rate for Payer: HFN Commercial |
$7,516.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,127.50
|
| Rate for Payer: Multiplan Commercial |
$6,536.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,902.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,516.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,003.30
|
| Rate for Payer: Quartz Commercial |
$5,310.50
|
| Rate for Payer: Quartz Medicare Advantage |
$4,902.00
|
| Rate for Payer: The Alliance Commercial |
$32,680.00
|
| Rate for Payer: WEA Trust Commercial |
$4,493.50
|
| Rate for Payer: WPS Commercial |
$6,051.52
|
|
|
TIBIAL PLATE SIZE 3 LEFT 71420164
|
Facility
|
IP
|
$18,121.00
|
|
| Hospital Charge Code |
2966054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,879.29 |
| Max. Negotiated Rate |
$16,671.32 |
| Rate for Payer: Aetna Commercial |
$16,308.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,584.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,604.13
|
| Rate for Payer: Cash Price |
$5,436.30
|
| Rate for Payer: Cigna Commercial |
$16,671.32
|
| Rate for Payer: Health EOS Commercial |
$16,127.69
|
| Rate for Payer: HFN Commercial |
$16,671.32
|
| Rate for Payer: Multiplan Commercial |
$14,496.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,872.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,671.32
|
| Rate for Payer: Quartz Beloit One Network |
$8,879.29
|
| Rate for Payer: Quartz Commercial |
$10,872.60
|
| Rate for Payer: WEA Trust Commercial |
$9,966.55
|
| Rate for Payer: WPS Commercial |
$13,422.22
|
|
|
TIBIAL PLATE SIZE 3 LEFT 71420164
|
Facility
|
OP
|
$18,121.00
|
|
| Hospital Charge Code |
2966054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,073.88 |
| Max. Negotiated Rate |
$72,484.00 |
| Rate for Payer: Aetna Commercial |
$16,308.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,584.06
|
| Rate for Payer: Aetna Managed Medicare |
$5,073.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,778.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,060.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,698.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,604.13
|
| Rate for Payer: Cash Price |
$5,436.30
|
| Rate for Payer: Cigna Commercial |
$16,671.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,140.51
|
| Rate for Payer: Health EOS Commercial |
$16,127.69
|
| Rate for Payer: HFN Commercial |
$16,671.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,590.75
|
| Rate for Payer: Multiplan Commercial |
$14,496.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,872.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,671.32
|
| Rate for Payer: Quartz Beloit One Network |
$8,879.29
|
| Rate for Payer: Quartz Commercial |
$11,778.65
|
| Rate for Payer: Quartz Medicare Advantage |
$10,872.60
|
| Rate for Payer: The Alliance Commercial |
$72,484.00
|
| Rate for Payer: WEA Trust Commercial |
$9,966.55
|
| Rate for Payer: WPS Commercial |
$13,422.22
|
|
|
TIBIAL PLATE SZ 4 5980-37-02
|
Facility
|
OP
|
$8,170.00
|
|
| Hospital Charge Code |
2967759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,287.60 |
| Max. Negotiated Rate |
$32,680.00 |
| Rate for Payer: Aetna Commercial |
$7,353.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,026.20
|
| Rate for Payer: Aetna Managed Medicare |
$2,287.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,310.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,330.10
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$7,516.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,571.93
|
| Rate for Payer: Health EOS Commercial |
$7,271.30
|
| Rate for Payer: HFN Commercial |
$7,516.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,127.50
|
| Rate for Payer: Multiplan Commercial |
$6,536.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,902.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,516.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,003.30
|
| Rate for Payer: Quartz Commercial |
$5,310.50
|
| Rate for Payer: Quartz Medicare Advantage |
$4,902.00
|
| Rate for Payer: The Alliance Commercial |
$32,680.00
|
| Rate for Payer: WEA Trust Commercial |
$4,493.50
|
| Rate for Payer: WPS Commercial |
$6,051.52
|
|
|
TIBIAL PLATE SZ 4 5980-37-02
|
Facility
|
IP
|
$8,170.00
|
|
| Hospital Charge Code |
2967759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,003.30 |
| Max. Negotiated Rate |
$7,516.40 |
| Rate for Payer: Aetna Commercial |
$7,353.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,026.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,330.10
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$7,516.40
|
| Rate for Payer: Health EOS Commercial |
$7,271.30
|
| Rate for Payer: HFN Commercial |
$7,516.40
|
| Rate for Payer: Multiplan Commercial |
$6,536.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,902.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,516.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,003.30
|
| Rate for Payer: Quartz Commercial |
$4,902.00
|
| Rate for Payer: WEA Trust Commercial |
$4,493.50
|
| Rate for Payer: WPS Commercial |
$6,051.52
|
|
|
TIBIAL PLATE SZ 5 00-5980-047-01
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SZ 5 00-5980-047-01
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIALPLATE SZ 5 5980-47-01
|
Facility
|
IP
|
$6,084.00
|
|
| Hospital Charge Code |
5307141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,981.16 |
| Max. Negotiated Rate |
$5,597.28 |
| Rate for Payer: Aetna Commercial |
$5,475.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,232.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,224.52
|
| Rate for Payer: Cash Price |
$1,825.20
|
| Rate for Payer: Cigna Commercial |
$5,597.28
|
| Rate for Payer: Health EOS Commercial |
$5,414.76
|
| Rate for Payer: HFN Commercial |
$5,597.28
|
| Rate for Payer: Multiplan Commercial |
$4,867.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,597.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,981.16
|
| Rate for Payer: Quartz Commercial |
$3,650.40
|
| Rate for Payer: WEA Trust Commercial |
$3,346.20
|
| Rate for Payer: WPS Commercial |
$4,506.42
|
|
|
TIBIALPLATE SZ 5 5980-47-01
|
Facility
|
OP
|
$6,084.00
|
|
| Hospital Charge Code |
5307141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,703.52 |
| Max. Negotiated Rate |
$24,336.00 |
| Rate for Payer: Aetna Commercial |
$5,475.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,232.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,703.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,954.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,042.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,920.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,224.52
|
| Rate for Payer: Cash Price |
$1,825.20
|
| Rate for Payer: Cigna Commercial |
$5,597.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,404.61
|
| Rate for Payer: Health EOS Commercial |
$5,414.76
|
| Rate for Payer: HFN Commercial |
$5,597.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,563.00
|
| Rate for Payer: Multiplan Commercial |
$4,867.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,597.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,981.16
|
| Rate for Payer: Quartz Commercial |
$3,954.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,650.40
|
| Rate for Payer: The Alliance Commercial |
$24,336.00
|
| Rate for Payer: WEA Trust Commercial |
$3,346.20
|
| Rate for Payer: WPS Commercial |
$4,506.42
|
|
|
TIBIAL PLATE SZ 6 5980-47-02
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SZ 6 5980-47-02
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SZ 7 5980-57-01
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SZ 7 5980-57-01
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SZ 8 5980-57-02
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SZ 8 5980-57-02
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SZ 9 5980-57-03
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967541
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL PLATE SZ 9 5980-57-03
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967541
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL SHEATH INTRAFIX 30MM 254601
|
Facility
|
IP
|
$3,780.00
|
|
| Hospital Charge Code |
4520591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,852.20 |
| Max. Negotiated Rate |
$3,477.60 |
| Rate for Payer: Aetna Commercial |
$3,402.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,250.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,003.40
|
| Rate for Payer: Cash Price |
$1,134.00
|
| Rate for Payer: Cigna Commercial |
$3,477.60
|
| Rate for Payer: Health EOS Commercial |
$3,364.20
|
| Rate for Payer: HFN Commercial |
$3,477.60
|
| Rate for Payer: Multiplan Commercial |
$3,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,268.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,477.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,852.20
|
| Rate for Payer: Quartz Commercial |
$2,268.00
|
| Rate for Payer: WEA Trust Commercial |
$2,079.00
|
| Rate for Payer: WPS Commercial |
$2,799.85
|
|
|
TIBIAL SHEATH INTRAFIX 30MM 254601
|
Facility
|
OP
|
$3,780.00
|
|
| Hospital Charge Code |
4520591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,058.40 |
| Max. Negotiated Rate |
$15,120.00 |
| Rate for Payer: Aetna Commercial |
$3,402.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,250.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,058.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,457.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,890.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,814.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,003.40
|
| Rate for Payer: Cash Price |
$1,134.00
|
| Rate for Payer: Cigna Commercial |
$3,477.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,115.29
|
| Rate for Payer: Health EOS Commercial |
$3,364.20
|
| Rate for Payer: HFN Commercial |
$3,477.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,835.00
|
| Rate for Payer: Multiplan Commercial |
$3,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,268.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,477.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,852.20
|
| Rate for Payer: Quartz Commercial |
$2,457.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,268.00
|
| Rate for Payer: The Alliance Commercial |
$15,120.00
|
| Rate for Payer: WEA Trust Commercial |
$2,079.00
|
| Rate for Payer: WPS Commercial |
$2,799.85
|
|
