|
TIBIAL SLEEVE REVISION FULLY COATED ATTUNE 29MM 1511-11-201
|
Facility
|
OP
|
$17,856.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6244176
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,999.78 |
| Max. Negotiated Rate |
$71,425.44 |
| Rate for Payer: Aetna Commercial |
$16,070.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,356.47
|
| Rate for Payer: Aetna Managed Medicare |
$4,999.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,606.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,928.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,571.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,463.87
|
| Rate for Payer: Cash Price |
$5,356.91
|
| Rate for Payer: Cigna Commercial |
$16,427.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,992.42
|
| Rate for Payer: Health EOS Commercial |
$15,892.16
|
| Rate for Payer: HFN Commercial |
$16,427.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,392.27
|
| Rate for Payer: Multiplan Commercial |
$14,285.09
|
| Rate for Payer: NAPHCARE Commercial |
$10,713.82
|
| Rate for Payer: Preferred Network Access Commercial |
$16,427.85
|
| Rate for Payer: Quartz Beloit One Network |
$8,749.62
|
| Rate for Payer: Quartz Commercial |
$11,606.63
|
| Rate for Payer: Quartz Medicare Advantage |
$10,713.82
|
| Rate for Payer: The Alliance Commercial |
$71,425.44
|
| Rate for Payer: WEA Trust Commercial |
$9,821.00
|
| Rate for Payer: WPS Commercial |
$13,226.21
|
|
|
TIBIAL SLEEVE REVISION FULLY COATED ATTUNE 29MM 1511-11-201
|
Facility
|
IP
|
$17,856.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6244176
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,749.62 |
| Max. Negotiated Rate |
$16,427.85 |
| Rate for Payer: Aetna Commercial |
$16,070.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,356.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,463.87
|
| Rate for Payer: Cash Price |
$5,356.91
|
| Rate for Payer: Cigna Commercial |
$16,427.85
|
| Rate for Payer: Health EOS Commercial |
$15,892.16
|
| Rate for Payer: HFN Commercial |
$16,427.85
|
| Rate for Payer: Multiplan Commercial |
$14,285.09
|
| Rate for Payer: NAPHCARE Commercial |
$10,713.82
|
| Rate for Payer: Preferred Network Access Commercial |
$16,427.85
|
| Rate for Payer: Quartz Beloit One Network |
$8,749.62
|
| Rate for Payer: Quartz Commercial |
$10,713.82
|
| Rate for Payer: WEA Trust Commercial |
$9,821.00
|
| Rate for Payer: WPS Commercial |
$13,226.21
|
|
|
TIBIAL SLEEVE REVISION FULLY COATED ATTUNE 37MM 1511-11-202
|
Facility
|
OP
|
$27,408.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528750
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,674.24 |
| Max. Negotiated Rate |
$109,632.00 |
| Rate for Payer: Aetna Commercial |
$24,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,570.88
|
| Rate for Payer: Aetna Managed Medicare |
$7,674.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,815.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,155.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,526.24
|
| Rate for Payer: Cash Price |
$8,222.40
|
| Rate for Payer: Cigna Commercial |
$25,215.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,337.52
|
| Rate for Payer: Health EOS Commercial |
$24,393.12
|
| Rate for Payer: HFN Commercial |
$25,215.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,556.00
|
| Rate for Payer: Multiplan Commercial |
$21,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$16,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25,215.36
|
| Rate for Payer: Quartz Beloit One Network |
$13,429.92
|
| Rate for Payer: Quartz Commercial |
$17,815.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16,444.80
|
| Rate for Payer: The Alliance Commercial |
$109,632.00
|
| Rate for Payer: WEA Trust Commercial |
$15,074.40
|
| Rate for Payer: WPS Commercial |
$20,301.11
|
|
|
TIBIAL SLEEVE REVISION FULLY COATED ATTUNE 37MM 1511-11-202
|
Facility
|
IP
|
$27,408.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5528750
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,429.92 |
| Max. Negotiated Rate |
$25,215.36 |
| Rate for Payer: Aetna Commercial |
$24,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23,570.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,526.24
|
| Rate for Payer: Cash Price |
$8,222.40
|
| Rate for Payer: Cigna Commercial |
$25,215.36
|
| Rate for Payer: Health EOS Commercial |
$24,393.12
|
| Rate for Payer: HFN Commercial |
$25,215.36
|
| Rate for Payer: Multiplan Commercial |
$21,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$16,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25,215.36
|
| Rate for Payer: Quartz Beloit One Network |
$13,429.92
|
| Rate for Payer: Quartz Commercial |
$16,444.80
|
| Rate for Payer: WEA Trust Commercial |
$15,074.40
|
| Rate for Payer: WPS Commercial |
$20,301.11
|
|
|
TIBIAL TRAY INFINITY ADAPTIS SZ 2 33680002
|
Facility
|
OP
|
$39,477.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6175037
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,053.56 |
| Max. Negotiated Rate |
$157,908.00 |
| Rate for Payer: Aetna Commercial |
$35,529.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,950.22
|
| Rate for Payer: Aetna Managed Medicare |
$11,053.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,660.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,738.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,948.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,922.81
|
| Rate for Payer: Cash Price |
$11,843.10
|
| Rate for Payer: Cigna Commercial |
$36,318.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,091.33
|
| Rate for Payer: Health EOS Commercial |
$35,134.53
|
| Rate for Payer: HFN Commercial |
$36,318.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,607.75
|
| Rate for Payer: Multiplan Commercial |
$31,581.60
|
| Rate for Payer: NAPHCARE Commercial |
$23,686.20
|
| Rate for Payer: Preferred Network Access Commercial |
$36,318.84
|
| Rate for Payer: Quartz Beloit One Network |
$19,343.73
|
| Rate for Payer: Quartz Commercial |
$25,660.05
|
| Rate for Payer: Quartz Medicare Advantage |
$23,686.20
|
| Rate for Payer: The Alliance Commercial |
$157,908.00
|
| Rate for Payer: WEA Trust Commercial |
$21,712.35
|
| Rate for Payer: WPS Commercial |
$29,240.61
|
|
|
TIBIAL TRAY INFINITY ADAPTIS SZ 2 33680002
|
Facility
|
IP
|
$39,477.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6175037
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,343.73 |
| Max. Negotiated Rate |
$36,318.84 |
| Rate for Payer: Aetna Commercial |
$35,529.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,950.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,922.81
|
| Rate for Payer: Cash Price |
$11,843.10
|
| Rate for Payer: Cigna Commercial |
$36,318.84
|
| Rate for Payer: Health EOS Commercial |
$35,134.53
|
| Rate for Payer: HFN Commercial |
$36,318.84
|
| Rate for Payer: Multiplan Commercial |
$31,581.60
|
| Rate for Payer: NAPHCARE Commercial |
$23,686.20
|
| Rate for Payer: Preferred Network Access Commercial |
$36,318.84
|
| Rate for Payer: Quartz Beloit One Network |
$19,343.73
|
| Rate for Payer: Quartz Commercial |
$23,686.20
|
| Rate for Payer: WEA Trust Commercial |
$21,712.35
|
| Rate for Payer: WPS Commercial |
$29,240.61
|
|
|
TIBIAL TRAY INFINITY ADAPTIS SZ 3 33680003
|
Facility
|
OP
|
$39,861.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,161.08 |
| Max. Negotiated Rate |
$159,444.00 |
| Rate for Payer: Aetna Commercial |
$35,874.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34,280.46
|
| Rate for Payer: Aetna Managed Medicare |
$11,161.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,909.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,930.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,133.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21,126.33
|
| Rate for Payer: Cash Price |
$11,958.30
|
| Rate for Payer: Cigna Commercial |
$36,672.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,306.22
|
| Rate for Payer: Health EOS Commercial |
$35,476.29
|
| Rate for Payer: HFN Commercial |
$36,672.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,895.75
|
| Rate for Payer: Multiplan Commercial |
$31,888.80
|
| Rate for Payer: NAPHCARE Commercial |
$23,916.60
|
| Rate for Payer: Preferred Network Access Commercial |
$36,672.12
|
| Rate for Payer: Quartz Beloit One Network |
$19,531.89
|
| Rate for Payer: Quartz Commercial |
$25,909.65
|
| Rate for Payer: Quartz Medicare Advantage |
$23,916.60
|
| Rate for Payer: The Alliance Commercial |
$159,444.00
|
| Rate for Payer: WEA Trust Commercial |
$21,923.55
|
| Rate for Payer: WPS Commercial |
$29,525.04
|
|
|
TIBIAL TRAY INFINITY ADAPTIS SZ 3 33680003
|
Facility
|
IP
|
$39,861.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,531.89 |
| Max. Negotiated Rate |
$36,672.12 |
| Rate for Payer: Aetna Commercial |
$35,874.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34,280.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21,126.33
|
| Rate for Payer: Cash Price |
$11,958.30
|
| Rate for Payer: Cigna Commercial |
$36,672.12
|
| Rate for Payer: Health EOS Commercial |
$35,476.29
|
| Rate for Payer: HFN Commercial |
$36,672.12
|
| Rate for Payer: Multiplan Commercial |
$31,888.80
|
| Rate for Payer: NAPHCARE Commercial |
$23,916.60
|
| Rate for Payer: Preferred Network Access Commercial |
$36,672.12
|
| Rate for Payer: Quartz Beloit One Network |
$19,531.89
|
| Rate for Payer: Quartz Commercial |
$23,916.60
|
| Rate for Payer: WEA Trust Commercial |
$21,923.55
|
| Rate for Payer: WPS Commercial |
$29,525.04
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ B 154720
|
Facility
|
OP
|
$7,286.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603560
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.08 |
| Max. Negotiated Rate |
$29,144.00 |
| Rate for Payer: Aetna Commercial |
$6,557.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,265.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,735.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.58
|
| Rate for Payer: Cash Price |
$2,185.80
|
| Rate for Payer: Cigna Commercial |
$6,703.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.25
|
| Rate for Payer: Health EOS Commercial |
$6,484.54
|
| Rate for Payer: HFN Commercial |
$6,703.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.50
|
| Rate for Payer: Multiplan Commercial |
$5,828.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.14
|
| Rate for Payer: Quartz Commercial |
$4,735.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.60
|
| Rate for Payer: The Alliance Commercial |
$29,144.00
|
| Rate for Payer: WEA Trust Commercial |
$4,007.30
|
| Rate for Payer: WPS Commercial |
$5,396.74
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ B 154720
|
Facility
|
IP
|
$7,286.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603560
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,570.14 |
| Max. Negotiated Rate |
$6,703.12 |
| Rate for Payer: Aetna Commercial |
$6,557.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,265.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.58
|
| Rate for Payer: Cash Price |
$2,185.80
|
| Rate for Payer: Cigna Commercial |
$6,703.12
|
| Rate for Payer: Health EOS Commercial |
$6,484.54
|
| Rate for Payer: HFN Commercial |
$6,703.12
|
| Rate for Payer: Multiplan Commercial |
$5,828.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.14
|
| Rate for Payer: Quartz Commercial |
$4,371.60
|
| Rate for Payer: WEA Trust Commercial |
$4,007.30
|
| Rate for Payer: WPS Commercial |
$5,396.74
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ C 154722
|
Facility
|
IP
|
$7,286.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,570.14 |
| Max. Negotiated Rate |
$6,703.12 |
| Rate for Payer: Aetna Commercial |
$6,557.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,265.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.58
|
| Rate for Payer: Cash Price |
$2,185.80
|
| Rate for Payer: Cigna Commercial |
$6,703.12
|
| Rate for Payer: Health EOS Commercial |
$6,484.54
|
| Rate for Payer: HFN Commercial |
$6,703.12
|
| Rate for Payer: Multiplan Commercial |
$5,828.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.14
|
| Rate for Payer: Quartz Commercial |
$4,371.60
|
| Rate for Payer: WEA Trust Commercial |
$4,007.30
|
| Rate for Payer: WPS Commercial |
$5,396.74
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ C 154722
|
Facility
|
OP
|
$7,286.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.08 |
| Max. Negotiated Rate |
$29,144.00 |
| Rate for Payer: Aetna Commercial |
$6,557.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,265.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,735.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.58
|
| Rate for Payer: Cash Price |
$2,185.80
|
| Rate for Payer: Cigna Commercial |
$6,703.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.25
|
| Rate for Payer: Health EOS Commercial |
$6,484.54
|
| Rate for Payer: HFN Commercial |
$6,703.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.50
|
| Rate for Payer: Multiplan Commercial |
$5,828.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.14
|
| Rate for Payer: Quartz Commercial |
$4,735.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.60
|
| Rate for Payer: The Alliance Commercial |
$29,144.00
|
| Rate for Payer: WEA Trust Commercial |
$4,007.30
|
| Rate for Payer: WPS Commercial |
$5,396.74
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ D 154724
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5384758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.68 |
| Max. Negotiated Rate |
$28,024.00 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.56
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.50
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,553.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.60
|
| Rate for Payer: The Alliance Commercial |
$28,024.00
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ D 154724
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5384758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.94 |
| Max. Negotiated Rate |
$6,445.52 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,203.60
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ E 154726
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.94 |
| Max. Negotiated Rate |
$6,445.52 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,203.60
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ E 154726
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.68 |
| Max. Negotiated Rate |
$28,024.00 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.56
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.50
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,553.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.60
|
| Rate for Payer: The Alliance Commercial |
$28,024.00
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ B 154721
|
Facility
|
OP
|
$7,286.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.08 |
| Max. Negotiated Rate |
$29,144.00 |
| Rate for Payer: Aetna Commercial |
$6,557.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,265.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,735.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.58
|
| Rate for Payer: Cash Price |
$2,185.80
|
| Rate for Payer: Cigna Commercial |
$6,703.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.25
|
| Rate for Payer: Health EOS Commercial |
$6,484.54
|
| Rate for Payer: HFN Commercial |
$6,703.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.50
|
| Rate for Payer: Multiplan Commercial |
$5,828.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.14
|
| Rate for Payer: Quartz Commercial |
$4,735.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.60
|
| Rate for Payer: The Alliance Commercial |
$29,144.00
|
| Rate for Payer: WEA Trust Commercial |
$4,007.30
|
| Rate for Payer: WPS Commercial |
$5,396.74
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ B 154721
|
Facility
|
IP
|
$7,286.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,570.14 |
| Max. Negotiated Rate |
$6,703.12 |
| Rate for Payer: Aetna Commercial |
$6,557.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,265.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.58
|
| Rate for Payer: Cash Price |
$2,185.80
|
| Rate for Payer: Cigna Commercial |
$6,703.12
|
| Rate for Payer: Health EOS Commercial |
$6,484.54
|
| Rate for Payer: HFN Commercial |
$6,703.12
|
| Rate for Payer: Multiplan Commercial |
$5,828.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.14
|
| Rate for Payer: Quartz Commercial |
$4,371.60
|
| Rate for Payer: WEA Trust Commercial |
$4,007.30
|
| Rate for Payer: WPS Commercial |
$5,396.74
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ C 154723
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.68 |
| Max. Negotiated Rate |
$28,024.00 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.56
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.50
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,553.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.60
|
| Rate for Payer: The Alliance Commercial |
$28,024.00
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ C 154723
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.94 |
| Max. Negotiated Rate |
$6,445.52 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,203.60
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ D 154725
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5179208
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.68 |
| Max. Negotiated Rate |
$28,024.00 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.56
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.50
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,553.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.60
|
| Rate for Payer: The Alliance Commercial |
$28,024.00
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ D 154725
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5179208
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.94 |
| Max. Negotiated Rate |
$6,445.52 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,203.60
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ E 154727
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.68 |
| Max. Negotiated Rate |
$28,024.00 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,961.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,553.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,920.56
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,254.50
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,553.90
|
| Rate for Payer: Quartz Medicare Advantage |
$4,203.60
|
| Rate for Payer: The Alliance Commercial |
$28,024.00
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ E 154727
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,432.94 |
| Max. Negotiated Rate |
$6,445.52 |
| Rate for Payer: Aetna Commercial |
$6,305.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,025.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,713.18
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,445.52
|
| Rate for Payer: Health EOS Commercial |
$6,235.34
|
| Rate for Payer: HFN Commercial |
$6,445.52
|
| Rate for Payer: Multiplan Commercial |
$5,604.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,203.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,445.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,432.94
|
| Rate for Payer: Quartz Commercial |
$4,203.60
|
| Rate for Payer: WEA Trust Commercial |
$3,853.30
|
| Rate for Payer: WPS Commercial |
$5,189.34
|
|
|
TIBIAL TRAY ROTATING PLATFORM M.B.T. REVISION CEMENTED SZ 2.5 1294-35-125
|
Facility
|
IP
|
$35,435.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17,363.15 |
| Max. Negotiated Rate |
$32,600.20 |
| Rate for Payer: Aetna Commercial |
$31,891.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,474.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,780.55
|
| Rate for Payer: Cash Price |
$10,630.50
|
| Rate for Payer: Cigna Commercial |
$32,600.20
|
| Rate for Payer: Health EOS Commercial |
$31,537.15
|
| Rate for Payer: HFN Commercial |
$32,600.20
|
| Rate for Payer: Multiplan Commercial |
$28,348.00
|
| Rate for Payer: NAPHCARE Commercial |
$21,261.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32,600.20
|
| Rate for Payer: Quartz Beloit One Network |
$17,363.15
|
| Rate for Payer: Quartz Commercial |
$21,261.00
|
| Rate for Payer: WEA Trust Commercial |
$19,489.25
|
| Rate for Payer: WPS Commercial |
$26,246.70
|
|
