|
TIBIAL BASEPLATE TRIATHLON SZ 3 5521-B-300
|
Facility
|
OP
|
$9,499.00
|
|
| Hospital Charge Code |
3128846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,659.72 |
| Max. Negotiated Rate |
$37,996.00 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,659.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,174.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,559.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,315.64
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,124.25
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$6,174.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,699.40
|
| Rate for Payer: The Alliance Commercial |
$37,996.00
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 3 5521-B-300
|
Facility
|
IP
|
$9,499.00
|
|
| Hospital Charge Code |
3128846
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,654.51 |
| Max. Negotiated Rate |
$8,739.08 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$5,699.40
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 4 5521-B-400
|
Facility
|
OP
|
$9,499.00
|
|
| Hospital Charge Code |
3127478
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,659.72 |
| Max. Negotiated Rate |
$37,996.00 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,659.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,174.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,559.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,315.64
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,124.25
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$6,174.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,699.40
|
| Rate for Payer: The Alliance Commercial |
$37,996.00
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 4 5521-B-400
|
Facility
|
IP
|
$9,499.00
|
|
| Hospital Charge Code |
3127478
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,654.51 |
| Max. Negotiated Rate |
$8,739.08 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$5,699.40
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 5 5521-B-500
|
Facility
|
IP
|
$9,499.00
|
|
| Hospital Charge Code |
3072433
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,654.51 |
| Max. Negotiated Rate |
$8,739.08 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$5,699.40
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 5 5521-B-500
|
Facility
|
OP
|
$9,499.00
|
|
| Hospital Charge Code |
3072433
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,659.72 |
| Max. Negotiated Rate |
$37,996.00 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,659.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,174.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,559.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,315.64
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,124.25
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$6,174.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,699.40
|
| Rate for Payer: The Alliance Commercial |
$37,996.00
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 6 5521-B-600
|
Facility
|
IP
|
$9,499.00
|
|
| Hospital Charge Code |
3219468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,654.51 |
| Max. Negotiated Rate |
$8,739.08 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$5,699.40
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 6 5521-B-600
|
Facility
|
OP
|
$9,499.00
|
|
| Hospital Charge Code |
3219468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,659.72 |
| Max. Negotiated Rate |
$37,996.00 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,659.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,174.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,559.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,315.64
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,124.25
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$6,174.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,699.40
|
| Rate for Payer: The Alliance Commercial |
$37,996.00
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 7 5521-B-700
|
Facility
|
IP
|
$9,499.00
|
|
| Hospital Charge Code |
4074601
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,654.51 |
| Max. Negotiated Rate |
$8,739.08 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$5,699.40
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 7 5521-B-700
|
Facility
|
OP
|
$9,499.00
|
|
| Hospital Charge Code |
4074601
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,659.72 |
| Max. Negotiated Rate |
$37,996.00 |
| Rate for Payer: Aetna Commercial |
$8,549.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,169.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,659.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,174.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,749.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,559.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,034.47
|
| Rate for Payer: Cash Price |
$2,849.70
|
| Rate for Payer: Cigna Commercial |
$8,739.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,315.64
|
| Rate for Payer: Health EOS Commercial |
$8,454.11
|
| Rate for Payer: HFN Commercial |
$8,739.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,124.25
|
| Rate for Payer: Multiplan Commercial |
$7,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,699.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,739.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,654.51
|
| Rate for Payer: Quartz Commercial |
$6,174.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,699.40
|
| Rate for Payer: The Alliance Commercial |
$37,996.00
|
| Rate for Payer: WEA Trust Commercial |
$5,224.45
|
| Rate for Payer: WPS Commercial |
$7,035.91
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 8 5521-B-800
|
Facility
|
IP
|
$9,147.00
|
|
| Hospital Charge Code |
4493857
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,482.03 |
| Max. Negotiated Rate |
$8,415.24 |
| Rate for Payer: Aetna Commercial |
$8,232.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,866.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,847.91
|
| Rate for Payer: Cash Price |
$2,744.10
|
| Rate for Payer: Cigna Commercial |
$8,415.24
|
| Rate for Payer: Health EOS Commercial |
$8,140.83
|
| Rate for Payer: HFN Commercial |
$8,415.24
|
| Rate for Payer: Multiplan Commercial |
$7,317.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,488.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,415.24
|
| Rate for Payer: Quartz Beloit One Network |
$4,482.03
|
| Rate for Payer: Quartz Commercial |
$5,488.20
|
| Rate for Payer: WEA Trust Commercial |
$5,030.85
|
| Rate for Payer: WPS Commercial |
$6,775.18
|
|
|
TIBIAL BASEPLATE TRIATHLON SZ 8 5521-B-800
|
Facility
|
OP
|
$9,147.00
|
|
| Hospital Charge Code |
4493857
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,561.16 |
| Max. Negotiated Rate |
$36,588.00 |
| Rate for Payer: Aetna Commercial |
$8,232.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,866.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,561.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,945.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,573.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,390.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,847.91
|
| Rate for Payer: Cash Price |
$2,744.10
|
| Rate for Payer: Cigna Commercial |
$8,415.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,118.66
|
| Rate for Payer: Health EOS Commercial |
$8,140.83
|
| Rate for Payer: HFN Commercial |
$8,415.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,860.25
|
| Rate for Payer: Multiplan Commercial |
$7,317.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,488.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,415.24
|
| Rate for Payer: Quartz Beloit One Network |
$4,482.03
|
| Rate for Payer: Quartz Commercial |
$5,945.55
|
| Rate for Payer: Quartz Medicare Advantage |
$5,488.20
|
| Rate for Payer: The Alliance Commercial |
$36,588.00
|
| Rate for Payer: WEA Trust Commercial |
$5,030.85
|
| Rate for Payer: WPS Commercial |
$6,775.18
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 10 CEMENTED 1506-80-010
|
Facility
|
IP
|
$6,885.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6166144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,373.65 |
| Max. Negotiated Rate |
$6,334.20 |
| Rate for Payer: Aetna Commercial |
$6,196.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,921.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,649.05
|
| Rate for Payer: Cash Price |
$2,065.50
|
| Rate for Payer: Cigna Commercial |
$6,334.20
|
| Rate for Payer: Health EOS Commercial |
$6,127.65
|
| Rate for Payer: HFN Commercial |
$6,334.20
|
| Rate for Payer: Multiplan Commercial |
$5,508.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,131.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,334.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,373.65
|
| Rate for Payer: Quartz Commercial |
$4,131.00
|
| Rate for Payer: WEA Trust Commercial |
$3,786.75
|
| Rate for Payer: WPS Commercial |
$5,099.72
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 10 CEMENTED 1506-80-010
|
Facility
|
OP
|
$6,885.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6166144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,927.80 |
| Max. Negotiated Rate |
$27,540.00 |
| Rate for Payer: Aetna Commercial |
$6,196.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,921.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,927.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,475.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,442.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,304.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,649.05
|
| Rate for Payer: Cash Price |
$2,065.50
|
| Rate for Payer: Cigna Commercial |
$6,334.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,852.85
|
| Rate for Payer: Health EOS Commercial |
$6,127.65
|
| Rate for Payer: HFN Commercial |
$6,334.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,163.75
|
| Rate for Payer: Multiplan Commercial |
$5,508.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,131.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,334.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,373.65
|
| Rate for Payer: Quartz Commercial |
$4,475.25
|
| Rate for Payer: Quartz Medicare Advantage |
$4,131.00
|
| Rate for Payer: The Alliance Commercial |
$27,540.00
|
| Rate for Payer: WEA Trust Commercial |
$3,786.75
|
| Rate for Payer: WPS Commercial |
$5,099.72
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 2 CEMENTED 1506-80-002
|
Facility
|
IP
|
$5,674.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6182934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,780.26 |
| Max. Negotiated Rate |
$5,220.08 |
| Rate for Payer: Aetna Commercial |
$5,106.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.22
|
| Rate for Payer: Cash Price |
$1,702.20
|
| Rate for Payer: Cigna Commercial |
$5,220.08
|
| Rate for Payer: Health EOS Commercial |
$5,049.86
|
| Rate for Payer: HFN Commercial |
$5,220.08
|
| Rate for Payer: Multiplan Commercial |
$4,539.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,404.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.26
|
| Rate for Payer: Quartz Commercial |
$3,404.40
|
| Rate for Payer: WEA Trust Commercial |
$3,120.70
|
| Rate for Payer: WPS Commercial |
$4,202.73
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 2 CEMENTED 1506-80-002
|
Facility
|
OP
|
$5,674.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6182934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,588.72 |
| Max. Negotiated Rate |
$22,696.00 |
| Rate for Payer: Aetna Commercial |
$5,106.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,879.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,588.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,688.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,837.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,723.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,007.22
|
| Rate for Payer: Cash Price |
$1,702.20
|
| Rate for Payer: Cigna Commercial |
$5,220.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,175.17
|
| Rate for Payer: Health EOS Commercial |
$5,049.86
|
| Rate for Payer: HFN Commercial |
$5,220.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,255.50
|
| Rate for Payer: Multiplan Commercial |
$4,539.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,404.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,220.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,780.26
|
| Rate for Payer: Quartz Commercial |
$3,688.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,404.40
|
| Rate for Payer: The Alliance Commercial |
$22,696.00
|
| Rate for Payer: WEA Trust Commercial |
$3,120.70
|
| Rate for Payer: WPS Commercial |
$4,202.73
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 3 CEMENTED 1506-80-003
|
Facility
|
OP
|
$8,616.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521121
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,412.48 |
| Max. Negotiated Rate |
$34,464.00 |
| Rate for Payer: Aetna Commercial |
$7,754.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,409.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,412.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,600.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,308.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,135.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,566.48
|
| Rate for Payer: Cash Price |
$2,584.80
|
| Rate for Payer: Cigna Commercial |
$7,926.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,821.51
|
| Rate for Payer: Health EOS Commercial |
$7,668.24
|
| Rate for Payer: HFN Commercial |
$7,926.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,462.00
|
| Rate for Payer: Multiplan Commercial |
$6,892.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,926.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,221.84
|
| Rate for Payer: Quartz Commercial |
$5,600.40
|
| Rate for Payer: Quartz Medicare Advantage |
$5,169.60
|
| Rate for Payer: The Alliance Commercial |
$34,464.00
|
| Rate for Payer: WEA Trust Commercial |
$4,738.80
|
| Rate for Payer: WPS Commercial |
$6,381.87
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 3 CEMENTED 1506-80-003
|
Facility
|
IP
|
$8,616.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521121
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,221.84 |
| Max. Negotiated Rate |
$7,926.72 |
| Rate for Payer: Aetna Commercial |
$7,754.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,409.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,566.48
|
| Rate for Payer: Cash Price |
$2,584.80
|
| Rate for Payer: Cigna Commercial |
$7,926.72
|
| Rate for Payer: Health EOS Commercial |
$7,668.24
|
| Rate for Payer: HFN Commercial |
$7,926.72
|
| Rate for Payer: Multiplan Commercial |
$6,892.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,926.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,221.84
|
| Rate for Payer: Quartz Commercial |
$5,169.60
|
| Rate for Payer: WEA Trust Commercial |
$4,738.80
|
| Rate for Payer: WPS Commercial |
$6,381.87
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 4 CEMENTED 1506-80-004
|
Facility
|
IP
|
$8,616.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,221.84 |
| Max. Negotiated Rate |
$7,926.72 |
| Rate for Payer: Aetna Commercial |
$7,754.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,409.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,566.48
|
| Rate for Payer: Cash Price |
$2,584.80
|
| Rate for Payer: Cigna Commercial |
$7,926.72
|
| Rate for Payer: Health EOS Commercial |
$7,668.24
|
| Rate for Payer: HFN Commercial |
$7,926.72
|
| Rate for Payer: Multiplan Commercial |
$6,892.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,926.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,221.84
|
| Rate for Payer: Quartz Commercial |
$5,169.60
|
| Rate for Payer: WEA Trust Commercial |
$4,738.80
|
| Rate for Payer: WPS Commercial |
$6,381.87
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 4 CEMENTED 1506-80-004
|
Facility
|
OP
|
$8,616.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,412.48 |
| Max. Negotiated Rate |
$34,464.00 |
| Rate for Payer: Aetna Commercial |
$7,754.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,409.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,412.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,600.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,308.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,135.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,566.48
|
| Rate for Payer: Cash Price |
$2,584.80
|
| Rate for Payer: Cigna Commercial |
$7,926.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,821.51
|
| Rate for Payer: Health EOS Commercial |
$7,668.24
|
| Rate for Payer: HFN Commercial |
$7,926.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,462.00
|
| Rate for Payer: Multiplan Commercial |
$6,892.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,926.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,221.84
|
| Rate for Payer: Quartz Commercial |
$5,600.40
|
| Rate for Payer: Quartz Medicare Advantage |
$5,169.60
|
| Rate for Payer: The Alliance Commercial |
$34,464.00
|
| Rate for Payer: WEA Trust Commercial |
$4,738.80
|
| Rate for Payer: WPS Commercial |
$6,381.87
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 5 CEMENTED 1506-80-005
|
Facility
|
OP
|
$8,616.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,412.48 |
| Max. Negotiated Rate |
$34,464.00 |
| Rate for Payer: Aetna Commercial |
$7,754.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,409.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,412.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,600.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,308.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,135.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,566.48
|
| Rate for Payer: Cash Price |
$2,584.80
|
| Rate for Payer: Cigna Commercial |
$7,926.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,821.51
|
| Rate for Payer: Health EOS Commercial |
$7,668.24
|
| Rate for Payer: HFN Commercial |
$7,926.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,462.00
|
| Rate for Payer: Multiplan Commercial |
$6,892.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,926.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,221.84
|
| Rate for Payer: Quartz Commercial |
$5,600.40
|
| Rate for Payer: Quartz Medicare Advantage |
$5,169.60
|
| Rate for Payer: The Alliance Commercial |
$34,464.00
|
| Rate for Payer: WEA Trust Commercial |
$4,738.80
|
| Rate for Payer: WPS Commercial |
$6,381.87
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 5 CEMENTED 1506-80-005
|
Facility
|
IP
|
$8,616.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,221.84 |
| Max. Negotiated Rate |
$7,926.72 |
| Rate for Payer: Aetna Commercial |
$7,754.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,409.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,566.48
|
| Rate for Payer: Cash Price |
$2,584.80
|
| Rate for Payer: Cigna Commercial |
$7,926.72
|
| Rate for Payer: Health EOS Commercial |
$7,668.24
|
| Rate for Payer: HFN Commercial |
$7,926.72
|
| Rate for Payer: Multiplan Commercial |
$6,892.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,926.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,221.84
|
| Rate for Payer: Quartz Commercial |
$5,169.60
|
| Rate for Payer: WEA Trust Commercial |
$4,738.80
|
| Rate for Payer: WPS Commercial |
$6,381.87
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 6 CEMENTED1506-80-006
|
Facility
|
OP
|
$8,298.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5547244
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.44 |
| Max. Negotiated Rate |
$33,192.00 |
| Rate for Payer: Aetna Commercial |
$7,468.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,136.28
|
| Rate for Payer: Aetna Managed Medicare |
$2,323.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,393.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,983.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,397.94
|
| Rate for Payer: Cash Price |
$2,489.40
|
| Rate for Payer: Cigna Commercial |
$7,634.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,643.56
|
| Rate for Payer: Health EOS Commercial |
$7,385.22
|
| Rate for Payer: HFN Commercial |
$7,634.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,223.50
|
| Rate for Payer: Multiplan Commercial |
$6,638.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,978.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,634.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,066.02
|
| Rate for Payer: Quartz Commercial |
$5,393.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,978.80
|
| Rate for Payer: The Alliance Commercial |
$33,192.00
|
| Rate for Payer: WEA Trust Commercial |
$4,563.90
|
| Rate for Payer: WPS Commercial |
$6,146.33
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 6 CEMENTED1506-80-006
|
Facility
|
IP
|
$8,298.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5547244
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,066.02 |
| Max. Negotiated Rate |
$7,634.16 |
| Rate for Payer: Aetna Commercial |
$7,468.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,136.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,397.94
|
| Rate for Payer: Cash Price |
$2,489.40
|
| Rate for Payer: Cigna Commercial |
$7,634.16
|
| Rate for Payer: Health EOS Commercial |
$7,385.22
|
| Rate for Payer: HFN Commercial |
$7,634.16
|
| Rate for Payer: Multiplan Commercial |
$6,638.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,978.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,634.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,066.02
|
| Rate for Payer: Quartz Commercial |
$4,978.80
|
| Rate for Payer: WEA Trust Commercial |
$4,563.90
|
| Rate for Payer: WPS Commercial |
$6,146.33
|
|
|
TIBIAL BASE ROTATING PLATFORM ATTUNE SZ 7 CEMENTED 1506-80-007
|
Facility
|
IP
|
$8,298.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5521075
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,066.02 |
| Max. Negotiated Rate |
$7,634.16 |
| Rate for Payer: Aetna Commercial |
$7,468.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,136.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,397.94
|
| Rate for Payer: Cash Price |
$2,489.40
|
| Rate for Payer: Cigna Commercial |
$7,634.16
|
| Rate for Payer: Health EOS Commercial |
$7,385.22
|
| Rate for Payer: HFN Commercial |
$7,634.16
|
| Rate for Payer: Multiplan Commercial |
$6,638.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,978.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,634.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,066.02
|
| Rate for Payer: Quartz Commercial |
$4,978.80
|
| Rate for Payer: WEA Trust Commercial |
$4,563.90
|
| Rate for Payer: WPS Commercial |
$6,146.33
|
|
