|
TIBIA PERSONA 5 DEG STEMMED LT SZ D 42-5320-067-01
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779543
|
|
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 D 42-5320-067-01
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779543
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ E 42-5320-071-01
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267497
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ E 42-5320-071-01
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267497
|
|
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 F 42-5320-075-01
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583498
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ F 42-5320-075-01
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583498
|
|
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 G 42-5320-079-01
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3727503
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ G 42-5320-079-01
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3727503
|
|
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 H 42-5320-083-01
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267494
|
|
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 H 42-5320-083-01
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267494
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ J 42-5320-088-01
|
Facility
IP
|
$6,558.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,213.42 |
| Max. Negotiated Rate |
$6,033.36 |
| Rate for Payer: Aetna Commercial |
$5,902.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,475.74
|
| Rate for Payer: Cash Price |
$1,967.40
|
| Rate for Payer: Cigna Commercial |
$6,033.36
|
| Rate for Payer: Health EOS Commercial |
$5,836.62
|
| Rate for Payer: HFN Commercial |
$6,033.36
|
| Rate for Payer: Multiplan Commercial |
$5,246.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,934.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,033.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,213.42
|
| Rate for Payer: Quartz Commercial |
$3,934.80
|
| Rate for Payer: WEA Trust Commercial |
$3,606.90
|
| Rate for Payer: WPS Commercial |
$4,857.51
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ J 42-5320-088-01
|
Facility
OP
|
$6,558.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,836.24 |
| Max. Negotiated Rate |
$6,033.36 |
| Rate for Payer: Aetna Commercial |
$5,902.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,639.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,836.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,262.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,279.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,147.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,475.74
|
| Rate for Payer: Cash Price |
$1,967.40
|
| Rate for Payer: Cigna Commercial |
$6,033.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,669.86
|
| Rate for Payer: Health EOS Commercial |
$5,836.62
|
| Rate for Payer: HFN Commercial |
$6,033.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,918.50
|
| Rate for Payer: Multiplan Commercial |
$5,246.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,934.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,033.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,213.42
|
| Rate for Payer: Quartz Commercial |
$4,262.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,934.80
|
| Rate for Payer: WEA Trust Commercial |
$3,606.90
|
| Rate for Payer: WPS Commercial |
$4,857.51
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ C 42-5320-064-02
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3333503
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ C 42-5320-064-02
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3333503
|
|
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 RT SZ D 42-5320-067-02
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615499
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ D 42-5320-067-02
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615499
|
|
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 RT SZ E 42-5320-071-02
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221472
|
|
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 RT SZ E 42-5320-071-02
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221472
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ F 42-5320-075-02
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3381506
|
|
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 RT SZ F 42-5320-075-02
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3381506
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ G 42-5320-079-02
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3116527
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ G 42-5320-079-02
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3116527
|
|
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 RT SZ H 42-5320-083-02
|
Facility
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3739521
|
|
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
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ H 42-5320-083-02
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3739521
|
|
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 TRAY ZUK HIGH FLEX SZ 2 RT MED/LT LAT 5842-02-02
|
Facility
IP
|
$6,892.00
|
|
| Hospital Charge Code |
3241465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,377.08 |
| Max. Negotiated Rate |
$6,340.64 |
| Rate for Payer: Aetna Commercial |
$6,202.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,652.76
|
| Rate for Payer: Cash Price |
$2,067.60
|
| Rate for Payer: Cigna Commercial |
$6,340.64
|
| Rate for Payer: Health EOS Commercial |
$6,133.88
|
| Rate for Payer: HFN Commercial |
$6,340.64
|
| Rate for Payer: Multiplan Commercial |
$5,513.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,135.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,340.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,377.08
|
| Rate for Payer: Quartz Commercial |
$4,135.20
|
| Rate for Payer: WEA Trust Commercial |
$3,790.60
|
| Rate for Payer: WPS Commercial |
$5,104.90
|
|
