|
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 |
$6,703.12 |
| 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: 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 |
$6,445.52 |
| 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: 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: 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 |
$6,445.52 |
| 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: 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: 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 |
$6,445.52 |
| 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: 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: 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
OP
|
$35,435.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,921.80 |
| 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: Aetna Managed Medicare |
$9,921.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,032.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,717.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,008.80
|
| 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: Dean Health DHI/DHP/ASO |
$19,829.43
|
| Rate for Payer: Health EOS Commercial |
$31,537.15
|
| Rate for Payer: HFN Commercial |
$32,600.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,576.25
|
| 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 |
$23,032.75
|
| Rate for Payer: Quartz Medicare Advantage |
$21,261.00
|
| Rate for Payer: WEA Trust Commercial |
$19,489.25
|
| Rate for Payer: WPS Commercial |
$26,246.70
|
|
|
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: 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
|
|
|
TIBIAL WEDGE HALF SZ 16 DEG 5988-05-20
|
Facility
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 16 DEG 5988-05-20
|
Facility
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 3 16 DEG 5988-03-20
|
Facility
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 3 16 DEG 5988-03-20
|
Facility
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 4 16 DEG 5988-04-20
|
Facility
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974032
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 4 16 DEG 5988-04-20
|
Facility
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974032
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 6 15 DEG 5988-06-20
|
Facility
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 6 15 DEG 5988-06-20
|
Facility
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 7 16 DEG 5988-07-20
|
Facility
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974036
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL WEDGE HALF SZ 7 16 DEG 5988-07-20
|
Facility
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974036
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIA PERSONA 0 DEG NP KEL LT SZ G 42-5360-079-01
|
Facility
OP
|
$5,886.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,648.18 |
| Max. Negotiated Rate |
$5,415.44 |
| Rate for Payer: Aetna Commercial |
$5,297.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,062.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,648.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,826.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,943.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,825.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,119.77
|
| Rate for Payer: Cash Price |
$1,765.90
|
| Rate for Payer: Cigna Commercial |
$5,415.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,294.00
|
| Rate for Payer: Health EOS Commercial |
$5,238.85
|
| Rate for Payer: HFN Commercial |
$5,415.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,414.76
|
| Rate for Payer: Multiplan Commercial |
$4,709.08
|
| Rate for Payer: NAPHCARE Commercial |
$3,531.81
|
| Rate for Payer: Preferred Network Access Commercial |
$5,415.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,884.31
|
| Rate for Payer: Quartz Commercial |
$3,826.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,531.81
|
| Rate for Payer: WEA Trust Commercial |
$3,237.49
|
| Rate for Payer: WPS Commercial |
$4,360.02
|
|
|
TIBIA PERSONA 0 DEG NP KEL LT SZ G 42-5360-079-01
|
Facility
IP
|
$5,886.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,884.31 |
| Max. Negotiated Rate |
$5,415.44 |
| Rate for Payer: Aetna Commercial |
$5,297.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,119.77
|
| Rate for Payer: Cash Price |
$1,765.90
|
| Rate for Payer: Cigna Commercial |
$5,415.44
|
| Rate for Payer: Health EOS Commercial |
$5,238.85
|
| Rate for Payer: HFN Commercial |
$5,415.44
|
| Rate for Payer: Multiplan Commercial |
$4,709.08
|
| Rate for Payer: NAPHCARE Commercial |
$3,531.81
|
| Rate for Payer: Preferred Network Access Commercial |
$5,415.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,884.31
|
| Rate for Payer: Quartz Commercial |
$3,531.81
|
| Rate for Payer: WEA Trust Commercial |
$3,237.49
|
| Rate for Payer: WPS Commercial |
$4,360.02
|
|
|
TIBIA PERSONA 0 DEG POROUS SPK KEL RT SZ F 42-5350-075-02
|
Facility
IP
|
$7,163.28
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246162
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,510.01 |
| Max. Negotiated Rate |
$6,590.22 |
| Rate for Payer: Aetna Commercial |
$6,446.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,796.54
|
| Rate for Payer: Cash Price |
$2,148.98
|
| Rate for Payer: Cigna Commercial |
$6,590.22
|
| Rate for Payer: Health EOS Commercial |
$6,375.32
|
| Rate for Payer: HFN Commercial |
$6,590.22
|
| Rate for Payer: Multiplan Commercial |
$5,730.62
|
| Rate for Payer: NAPHCARE Commercial |
$4,297.97
|
| Rate for Payer: Preferred Network Access Commercial |
$6,590.22
|
| Rate for Payer: Quartz Beloit One Network |
$3,510.01
|
| Rate for Payer: Quartz Commercial |
$4,297.97
|
| Rate for Payer: WEA Trust Commercial |
$3,939.80
|
| Rate for Payer: WPS Commercial |
$5,305.84
|
|
|
TIBIA PERSONA 0 DEG POROUS SPK KEL RT SZ F 42-5350-075-02
|
Facility
OP
|
$7,163.28
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246162
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,005.72 |
| Max. Negotiated Rate |
$6,590.22 |
| Rate for Payer: Aetna Commercial |
$6,446.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,160.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,005.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,656.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,581.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,438.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,796.54
|
| Rate for Payer: Cash Price |
$2,148.98
|
| Rate for Payer: Cigna Commercial |
$6,590.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,008.57
|
| Rate for Payer: Health EOS Commercial |
$6,375.32
|
| Rate for Payer: HFN Commercial |
$6,590.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,372.46
|
| Rate for Payer: Multiplan Commercial |
$5,730.62
|
| Rate for Payer: NAPHCARE Commercial |
$4,297.97
|
| Rate for Payer: Preferred Network Access Commercial |
$6,590.22
|
| Rate for Payer: Quartz Beloit One Network |
$3,510.01
|
| Rate for Payer: Quartz Commercial |
$4,656.13
|
| Rate for Payer: Quartz Medicare Advantage |
$4,297.97
|
| Rate for Payer: WEA Trust Commercial |
$3,939.80
|
| Rate for Payer: WPS Commercial |
$5,305.84
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ C 42-5320-064-01
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.96 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,136.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,960.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,663.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,270.87
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,724.00
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ C 42-5320-064-01
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,739.68 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
