|
TIBIAL BEARING INSERT TRIATHLON PS SZ 2 13MM 5532-G-213
|
Facility
|
IP
|
$8,080.00
|
|
| Hospital Charge Code |
4493911
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,117.57 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,041.92
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 2 16MM 5532-G-216
|
Facility
|
IP
|
$8,080.00
|
|
| Hospital Charge Code |
4493912
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,117.57 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,041.92
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 2 16MM 5532-G-216
|
Facility
|
OP
|
$8,080.00
|
|
| Hospital Charge Code |
4493912
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,352.90 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Aetna Managed Medicare |
$2,352.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,462.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,201.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,033.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,702.56
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,302.40
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: NAPHCARE Commercial |
$5,041.92
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,462.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,041.92
|
| Rate for Payer: The Alliance Commercial |
$4,201.60
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 2 19MM 5532-G-219
|
Facility
|
OP
|
$8,080.00
|
|
| Hospital Charge Code |
4493913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,352.90 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Aetna Managed Medicare |
$2,352.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,462.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,201.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,033.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,702.56
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,302.40
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: NAPHCARE Commercial |
$5,041.92
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,462.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,041.92
|
| Rate for Payer: The Alliance Commercial |
$4,201.60
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 2 19MM 5532-G-219
|
Facility
|
IP
|
$8,080.00
|
|
| Hospital Charge Code |
4493913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,117.57 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,041.92
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 2 9MM 5532-G-209
|
Facility
|
IP
|
$8,080.00
|
|
| Hospital Charge Code |
4493903
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,117.57 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,041.92
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 2 9MM 5532-G-209
|
Facility
|
OP
|
$8,080.00
|
|
| Hospital Charge Code |
4493903
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,352.90 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Aetna Managed Medicare |
$2,352.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,462.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,201.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,033.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,702.56
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,302.40
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: NAPHCARE Commercial |
$5,041.92
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,462.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,041.92
|
| Rate for Payer: The Alliance Commercial |
$4,201.60
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 3 11MM 5532-G-311
|
Facility
|
OP
|
$8,080.00
|
|
| Hospital Charge Code |
4493914
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,352.90 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Aetna Managed Medicare |
$2,352.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,462.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,201.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,033.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,702.56
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,302.40
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: NAPHCARE Commercial |
$5,041.92
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,462.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,041.92
|
| Rate for Payer: The Alliance Commercial |
$4,201.60
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 3 11MM 5532-G-311
|
Facility
|
IP
|
$8,080.00
|
|
| Hospital Charge Code |
4493914
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,117.57 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,041.92
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 3 19MM 5532-G-319
|
Facility
|
IP
|
$8,080.00
|
|
| Hospital Charge Code |
4493916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,117.57 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,041.92
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BEARING INSERT TRIATHLON PS SZ 3 19MM 5532-G-319
|
Facility
|
OP
|
$8,080.00
|
|
| Hospital Charge Code |
4493916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,352.90 |
| Max. Negotiated Rate |
$7,730.94 |
| Rate for Payer: Aetna Commercial |
$7,562.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,226.75
|
| Rate for Payer: Aetna Managed Medicare |
$2,352.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,462.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,201.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,033.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,453.70
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,730.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,702.56
|
| Rate for Payer: Health EOS Commercial |
$7,478.85
|
| Rate for Payer: HFN Commercial |
$7,730.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,302.40
|
| Rate for Payer: Multiplan Commercial |
$6,722.56
|
| Rate for Payer: NAPHCARE Commercial |
$5,041.92
|
| Rate for Payer: Preferred Network Access Commercial |
$7,730.94
|
| Rate for Payer: Quartz Beloit One Network |
$4,117.57
|
| Rate for Payer: Quartz Commercial |
$5,462.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,041.92
|
| Rate for Payer: The Alliance Commercial |
$4,201.60
|
| Rate for Payer: WEA Trust Commercial |
$4,621.76
|
| Rate for Payer: WPS Commercial |
$6,224.02
|
|
|
TIBIAL BLOCK SZ 3 5MM THICK 00-5988-003-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2969405
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 3 5MM THICK 00-5988-003-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2969405
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 4 5MM THICK 5988-04-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 4 5MM THICK 5988-04-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 5 5MM THICK 5988-05-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2973967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 5 5MM THICK 5988-05-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2973967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 6 5MM THICK 5988-06-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 6 5MM THICK 5988-06-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 7 5MM THICK 5988-07-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974037
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BLOCK SZ 7 5MM THICK 5988-07-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974037
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL BONE GRAFTING
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2959866
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,125.03 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,602.08
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
TIBIAL BONE GRAFTING
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2959866
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,214.30 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,214.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,818.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,168.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,081.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,426.94
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,252.60
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,602.08
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,818.92
|
| Rate for Payer: Quartz Medicare Advantage |
$2,602.08
|
| Rate for Payer: The Alliance Commercial |
$2,168.40
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
TIBIAL COMPONENT P.F.C. SIGMA ALL POLY CURVE SZ 3 10MM CEMENTED 96-0641
|
Facility
|
IP
|
$7,868.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787647
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,009.53 |
| Max. Negotiated Rate |
$7,528.10 |
| Rate for Payer: Aetna Commercial |
$7,364.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,037.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,336.84
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,528.10
|
| Rate for Payer: Health EOS Commercial |
$7,282.62
|
| Rate for Payer: HFN Commercial |
$7,528.10
|
| Rate for Payer: Multiplan Commercial |
$6,546.18
|
| Rate for Payer: Preferred Network Access Commercial |
$7,528.10
|
| Rate for Payer: Quartz Beloit One Network |
$4,009.53
|
| Rate for Payer: Quartz Commercial |
$4,909.63
|
| Rate for Payer: WEA Trust Commercial |
$4,500.50
|
| Rate for Payer: WPS Commercial |
$6,060.72
|
|
|
TIBIAL COMPONENT P.F.C. SIGMA ALL POLY CURVE SZ 3 10MM CEMENTED 96-0641
|
Facility
|
OP
|
$7,868.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787647
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,291.16 |
| Max. Negotiated Rate |
$7,528.10 |
| Rate for Payer: Aetna Commercial |
$7,364.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,037.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,291.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,318.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,091.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,927.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,336.84
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,528.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,579.18
|
| Rate for Payer: Health EOS Commercial |
$7,282.62
|
| Rate for Payer: HFN Commercial |
$7,528.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,137.04
|
| Rate for Payer: Multiplan Commercial |
$6,546.18
|
| Rate for Payer: NAPHCARE Commercial |
$4,909.63
|
| Rate for Payer: Preferred Network Access Commercial |
$7,528.10
|
| Rate for Payer: Quartz Beloit One Network |
$4,009.53
|
| Rate for Payer: Quartz Commercial |
$5,318.77
|
| Rate for Payer: Quartz Medicare Advantage |
$4,909.63
|
| Rate for Payer: The Alliance Commercial |
$4,091.36
|
| Rate for Payer: WEA Trust Commercial |
$4,500.50
|
| Rate for Payer: WPS Commercial |
$6,060.72
|
|
