|
TIBIAL NEXGEN MONOBLOCK TRABECULAR CR SZ 5 FEMUR SZ C-H 00-5886-045-14
|
Facility
|
IP
|
$12,925.00
|
|
| Hospital Charge Code |
5349220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,586.58 |
| Max. Negotiated Rate |
$12,366.64 |
| Rate for Payer: Aetna Commercial |
$12,097.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,560.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,124.26
|
| Rate for Payer: Cash Price |
$3,877.50
|
| Rate for Payer: Cigna Commercial |
$12,366.64
|
| Rate for Payer: Health EOS Commercial |
$11,963.38
|
| Rate for Payer: HFN Commercial |
$12,366.64
|
| Rate for Payer: Multiplan Commercial |
$10,753.60
|
| Rate for Payer: Preferred Network Access Commercial |
$12,366.64
|
| Rate for Payer: Quartz Beloit One Network |
$6,586.58
|
| Rate for Payer: Quartz Commercial |
$8,065.20
|
| Rate for Payer: WEA Trust Commercial |
$7,393.10
|
| Rate for Payer: WPS Commercial |
$9,956.13
|
|
|
TIBIAL NEXGEN MONOBLOCK TRABECULAR CR SZ 5 FEMUR SZ E-F 00-5886-045-12
|
Facility
|
OP
|
$12,447.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,624.57 |
| Max. Negotiated Rate |
$11,909.29 |
| Rate for Payer: Aetna Commercial |
$11,650.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,132.60
|
| Rate for Payer: Aetna Managed Medicare |
$3,624.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,414.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,472.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,213.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,860.79
|
| Rate for Payer: Cash Price |
$3,734.10
|
| Rate for Payer: Cigna Commercial |
$11,909.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,244.15
|
| Rate for Payer: Health EOS Commercial |
$11,520.94
|
| Rate for Payer: HFN Commercial |
$11,909.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,708.66
|
| Rate for Payer: Multiplan Commercial |
$10,355.90
|
| Rate for Payer: NAPHCARE Commercial |
$7,766.93
|
| Rate for Payer: Preferred Network Access Commercial |
$11,909.29
|
| Rate for Payer: Quartz Beloit One Network |
$6,342.99
|
| Rate for Payer: Quartz Commercial |
$8,414.17
|
| Rate for Payer: Quartz Medicare Advantage |
$7,766.93
|
| Rate for Payer: The Alliance Commercial |
$6,472.44
|
| Rate for Payer: WEA Trust Commercial |
$7,119.68
|
| Rate for Payer: WPS Commercial |
$9,587.92
|
|
|
TIBIAL NEXGEN MONOBLOCK TRABECULAR CR SZ 5 FEMUR SZ E-F 00-5886-045-12
|
Facility
|
IP
|
$12,447.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,342.99 |
| Max. Negotiated Rate |
$11,909.29 |
| Rate for Payer: Aetna Commercial |
$11,650.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,132.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,860.79
|
| Rate for Payer: Cash Price |
$3,734.10
|
| Rate for Payer: Cigna Commercial |
$11,909.29
|
| Rate for Payer: Health EOS Commercial |
$11,520.94
|
| Rate for Payer: HFN Commercial |
$11,909.29
|
| Rate for Payer: Multiplan Commercial |
$10,355.90
|
| Rate for Payer: Preferred Network Access Commercial |
$11,909.29
|
| Rate for Payer: Quartz Beloit One Network |
$6,342.99
|
| Rate for Payer: Quartz Commercial |
$7,766.93
|
| Rate for Payer: WEA Trust Commercial |
$7,119.68
|
| Rate for Payer: WPS Commercial |
$9,587.92
|
|
|
TIBIAL NEXGEN MONOBLOCK TRABECULAR CR SZ 7 FEMUR SZ G-H 12MM 00-5886-047-12
|
Facility
|
IP
|
$12,447.00
|
|
| Hospital Charge Code |
5456755
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,342.99 |
| Max. Negotiated Rate |
$11,909.29 |
| Rate for Payer: Aetna Commercial |
$11,650.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,132.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,860.79
|
| Rate for Payer: Cash Price |
$3,734.10
|
| Rate for Payer: Cigna Commercial |
$11,909.29
|
| Rate for Payer: Health EOS Commercial |
$11,520.94
|
| Rate for Payer: HFN Commercial |
$11,909.29
|
| Rate for Payer: Multiplan Commercial |
$10,355.90
|
| Rate for Payer: Preferred Network Access Commercial |
$11,909.29
|
| Rate for Payer: Quartz Beloit One Network |
$6,342.99
|
| Rate for Payer: Quartz Commercial |
$7,766.93
|
| Rate for Payer: WEA Trust Commercial |
$7,119.68
|
| Rate for Payer: WPS Commercial |
$9,587.92
|
|
|
TIBIAL NEXGEN MONOBLOCK TRABECULAR CR SZ 7 FEMUR SZ G-H 12MM 00-5886-047-12
|
Facility
|
OP
|
$12,447.00
|
|
| Hospital Charge Code |
5456755
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,624.57 |
| Max. Negotiated Rate |
$11,909.29 |
| Rate for Payer: Aetna Commercial |
$11,650.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,132.60
|
| Rate for Payer: Aetna Managed Medicare |
$3,624.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,414.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,472.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,213.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,860.79
|
| Rate for Payer: Cash Price |
$3,734.10
|
| Rate for Payer: Cigna Commercial |
$11,909.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,244.15
|
| Rate for Payer: Health EOS Commercial |
$11,520.94
|
| Rate for Payer: HFN Commercial |
$11,909.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,708.66
|
| Rate for Payer: Multiplan Commercial |
$10,355.90
|
| Rate for Payer: NAPHCARE Commercial |
$7,766.93
|
| Rate for Payer: Preferred Network Access Commercial |
$11,909.29
|
| Rate for Payer: Quartz Beloit One Network |
$6,342.99
|
| Rate for Payer: Quartz Commercial |
$8,414.17
|
| Rate for Payer: Quartz Medicare Advantage |
$7,766.93
|
| Rate for Payer: The Alliance Commercial |
$6,472.44
|
| Rate for Payer: WEA Trust Commercial |
$7,119.68
|
| Rate for Payer: WPS Commercial |
$9,587.92
|
|
|
TIBIAL OBTURATOR AS D12MM NN261Z
|
Facility
|
IP
|
$3,688.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6049670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,879.40 |
| Max. Negotiated Rate |
$3,528.68 |
| Rate for Payer: Aetna Commercial |
$3,451.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,298.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,032.83
|
| Rate for Payer: Cash Price |
$1,106.40
|
| Rate for Payer: Cigna Commercial |
$3,528.68
|
| Rate for Payer: Health EOS Commercial |
$3,413.61
|
| Rate for Payer: HFN Commercial |
$3,528.68
|
| Rate for Payer: Multiplan Commercial |
$3,068.42
|
| Rate for Payer: Preferred Network Access Commercial |
$3,528.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,879.40
|
| Rate for Payer: Quartz Commercial |
$2,301.31
|
| Rate for Payer: WEA Trust Commercial |
$2,109.54
|
| Rate for Payer: WPS Commercial |
$2,840.87
|
|
|
TIBIAL OBTURATOR AS D12MM NN261Z
|
Facility
|
OP
|
$3,688.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6049670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.95 |
| Max. Negotiated Rate |
$3,528.68 |
| Rate for Payer: Aetna Commercial |
$3,451.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,298.55
|
| Rate for Payer: Aetna Managed Medicare |
$1,073.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,493.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,917.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,841.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,032.83
|
| Rate for Payer: Cash Price |
$1,106.40
|
| Rate for Payer: Cigna Commercial |
$3,528.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,146.42
|
| Rate for Payer: Health EOS Commercial |
$3,413.61
|
| Rate for Payer: HFN Commercial |
$3,528.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,876.64
|
| Rate for Payer: Multiplan Commercial |
$3,068.42
|
| Rate for Payer: NAPHCARE Commercial |
$2,301.31
|
| Rate for Payer: Preferred Network Access Commercial |
$3,528.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,879.40
|
| Rate for Payer: Quartz Commercial |
$2,493.09
|
| Rate for Payer: Quartz Medicare Advantage |
$2,301.31
|
| Rate for Payer: The Alliance Commercial |
$1,917.76
|
| Rate for Payer: WEA Trust Commercial |
$2,109.54
|
| Rate for Payer: WPS Commercial |
$2,840.87
|
|
|
TIBIAL PLATEAU AS VEGA PS CEMENTED T2 NX053Z
|
Facility
|
OP
|
$8,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,506.07 |
| Max. Negotiated Rate |
$8,234.22 |
| Rate for Payer: Aetna Commercial |
$8,055.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,697.21
|
| Rate for Payer: Aetna Managed Medicare |
$2,506.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,817.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,475.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,296.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,743.63
|
| Rate for Payer: Cash Price |
$2,581.80
|
| Rate for Payer: Cigna Commercial |
$8,234.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,008.69
|
| Rate for Payer: Health EOS Commercial |
$7,965.71
|
| Rate for Payer: HFN Commercial |
$8,234.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,712.68
|
| Rate for Payer: Multiplan Commercial |
$7,160.19
|
| Rate for Payer: NAPHCARE Commercial |
$5,370.14
|
| Rate for Payer: Preferred Network Access Commercial |
$8,234.22
|
| Rate for Payer: Quartz Beloit One Network |
$4,385.62
|
| Rate for Payer: Quartz Commercial |
$5,817.66
|
| Rate for Payer: Quartz Medicare Advantage |
$5,370.14
|
| Rate for Payer: The Alliance Commercial |
$4,475.12
|
| Rate for Payer: WEA Trust Commercial |
$4,922.63
|
| Rate for Payer: WPS Commercial |
$6,629.20
|
|
|
TIBIAL PLATEAU AS VEGA PS CEMENTED T2 NX053Z
|
Facility
|
IP
|
$8,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,385.62 |
| Max. Negotiated Rate |
$8,234.22 |
| Rate for Payer: Aetna Commercial |
$8,055.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,697.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,743.63
|
| Rate for Payer: Cash Price |
$2,581.80
|
| Rate for Payer: Cigna Commercial |
$8,234.22
|
| Rate for Payer: Health EOS Commercial |
$7,965.71
|
| Rate for Payer: HFN Commercial |
$8,234.22
|
| Rate for Payer: Multiplan Commercial |
$7,160.19
|
| Rate for Payer: Preferred Network Access Commercial |
$8,234.22
|
| Rate for Payer: Quartz Beloit One Network |
$4,385.62
|
| Rate for Payer: Quartz Commercial |
$5,370.14
|
| Rate for Payer: WEA Trust Commercial |
$4,922.63
|
| Rate for Payer: WPS Commercial |
$6,629.20
|
|
|
TIBIAL PLATEAU AS VEGA PS CEMENTED T3 NX055Z
|
Facility
|
OP
|
$8,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6049668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,506.07 |
| Max. Negotiated Rate |
$8,234.22 |
| Rate for Payer: Aetna Commercial |
$8,055.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,697.21
|
| Rate for Payer: Aetna Managed Medicare |
$2,506.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,817.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,475.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,296.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,743.63
|
| Rate for Payer: Cash Price |
$2,581.80
|
| Rate for Payer: Cigna Commercial |
$8,234.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,008.69
|
| Rate for Payer: Health EOS Commercial |
$7,965.71
|
| Rate for Payer: HFN Commercial |
$8,234.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,712.68
|
| Rate for Payer: Multiplan Commercial |
$7,160.19
|
| Rate for Payer: NAPHCARE Commercial |
$5,370.14
|
| Rate for Payer: Preferred Network Access Commercial |
$8,234.22
|
| Rate for Payer: Quartz Beloit One Network |
$4,385.62
|
| Rate for Payer: Quartz Commercial |
$5,817.66
|
| Rate for Payer: Quartz Medicare Advantage |
$5,370.14
|
| Rate for Payer: The Alliance Commercial |
$4,475.12
|
| Rate for Payer: WEA Trust Commercial |
$4,922.63
|
| Rate for Payer: WPS Commercial |
$6,629.20
|
|
|
TIBIAL PLATEAU AS VEGA PS CEMENTED T3 NX055Z
|
Facility
|
IP
|
$8,606.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6049668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,385.62 |
| Max. Negotiated Rate |
$8,234.22 |
| Rate for Payer: Aetna Commercial |
$8,055.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,697.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,743.63
|
| Rate for Payer: Cash Price |
$2,581.80
|
| Rate for Payer: Cigna Commercial |
$8,234.22
|
| Rate for Payer: Health EOS Commercial |
$7,965.71
|
| Rate for Payer: HFN Commercial |
$8,234.22
|
| Rate for Payer: Multiplan Commercial |
$7,160.19
|
| Rate for Payer: Preferred Network Access Commercial |
$8,234.22
|
| Rate for Payer: Quartz Beloit One Network |
$4,385.62
|
| Rate for Payer: Quartz Commercial |
$5,370.14
|
| Rate for Payer: WEA Trust Commercial |
$4,922.63
|
| Rate for Payer: WPS Commercial |
$6,629.20
|
|
|
TIBIAL PLATE ROTATING HINGE NEXGEN STEMMED RT SZ 3 00-5880-003-00
|
Facility
|
IP
|
$20,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,566.56 |
| Max. Negotiated Rate |
$19,839.25 |
| Rate for Payer: Aetna Commercial |
$19,407.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,545.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,429.13
|
| Rate for Payer: Cash Price |
$6,220.50
|
| Rate for Payer: Cigna Commercial |
$19,839.25
|
| Rate for Payer: Health EOS Commercial |
$19,192.32
|
| Rate for Payer: HFN Commercial |
$19,839.25
|
| Rate for Payer: Multiplan Commercial |
$17,251.52
|
| Rate for Payer: Preferred Network Access Commercial |
$19,839.25
|
| Rate for Payer: Quartz Beloit One Network |
$10,566.56
|
| Rate for Payer: Quartz Commercial |
$12,938.64
|
| Rate for Payer: WEA Trust Commercial |
$11,860.42
|
| Rate for Payer: WPS Commercial |
$15,972.17
|
|
|
TIBIAL PLATE ROTATING HINGE NEXGEN STEMMED RT SZ 3 00-5880-003-00
|
Facility
|
OP
|
$20,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,038.03 |
| Max. Negotiated Rate |
$19,839.25 |
| Rate for Payer: Aetna Commercial |
$19,407.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,545.38
|
| Rate for Payer: Aetna Managed Medicare |
$6,038.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,016.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,782.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,350.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,429.13
|
| Rate for Payer: Cash Price |
$6,220.50
|
| Rate for Payer: Cigna Commercial |
$19,839.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,067.77
|
| Rate for Payer: Health EOS Commercial |
$19,192.32
|
| Rate for Payer: HFN Commercial |
$19,839.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,173.30
|
| Rate for Payer: Multiplan Commercial |
$17,251.52
|
| Rate for Payer: NAPHCARE Commercial |
$12,938.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,839.25
|
| Rate for Payer: Quartz Beloit One Network |
$10,566.56
|
| Rate for Payer: Quartz Commercial |
$14,016.86
|
| Rate for Payer: Quartz Medicare Advantage |
$12,938.64
|
| Rate for Payer: The Alliance Commercial |
$10,782.20
|
| Rate for Payer: WEA Trust Commercial |
$11,860.42
|
| Rate for Payer: WPS Commercial |
$15,972.17
|
|
|
TIBIAL PLATE SIZE 1 MICRO 5980-27-01
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967539
|
|
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
|
|
|
TIBIAL PLATE SIZE 1 MICRO 5980-27-01
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967539
|
|
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 PLATE SIZE 2 MICRO 5980-27-02
|
Facility
|
OP
|
$9,587.00
|
|
| Hospital Charge Code |
2967540
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,791.73 |
| Max. Negotiated Rate |
$9,172.84 |
| Rate for Payer: Aetna Commercial |
$8,973.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,574.61
|
| Rate for Payer: Aetna Managed Medicare |
$2,791.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,480.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,985.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,785.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,284.35
|
| Rate for Payer: Cash Price |
$2,876.10
|
| Rate for Payer: Cigna Commercial |
$9,172.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,579.63
|
| Rate for Payer: Health EOS Commercial |
$8,873.73
|
| Rate for Payer: HFN Commercial |
$9,172.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,477.86
|
| Rate for Payer: Multiplan Commercial |
$7,976.38
|
| Rate for Payer: NAPHCARE Commercial |
$5,982.29
|
| Rate for Payer: Preferred Network Access Commercial |
$9,172.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,885.54
|
| Rate for Payer: Quartz Commercial |
$6,480.81
|
| Rate for Payer: Quartz Medicare Advantage |
$5,982.29
|
| Rate for Payer: The Alliance Commercial |
$4,985.24
|
| Rate for Payer: WEA Trust Commercial |
$5,483.76
|
| Rate for Payer: WPS Commercial |
$7,384.87
|
|
|
TIBIAL PLATE SIZE 2 MICRO 5980-27-02
|
Facility
|
IP
|
$9,587.00
|
|
| Hospital Charge Code |
2967540
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,885.54 |
| Max. Negotiated Rate |
$9,172.84 |
| Rate for Payer: Aetna Commercial |
$8,973.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,574.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,284.35
|
| Rate for Payer: Cash Price |
$2,876.10
|
| Rate for Payer: Cigna Commercial |
$9,172.84
|
| Rate for Payer: Health EOS Commercial |
$8,873.73
|
| Rate for Payer: HFN Commercial |
$9,172.84
|
| Rate for Payer: Multiplan Commercial |
$7,976.38
|
| Rate for Payer: Preferred Network Access Commercial |
$9,172.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,885.54
|
| Rate for Payer: Quartz Commercial |
$5,982.29
|
| Rate for Payer: WEA Trust Commercial |
$5,483.76
|
| Rate for Payer: WPS Commercial |
$7,384.87
|
|
|
TIBIAL PLATE SIZE 3 5980-37-01
|
Facility
|
OP
|
$8,170.00
|
|
| Hospital Charge Code |
2967758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,379.10 |
| Max. Negotiated Rate |
$7,817.06 |
| Rate for Payer: Aetna Commercial |
$7,647.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,307.25
|
| Rate for Payer: Aetna Managed Medicare |
$2,379.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,522.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,248.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,078.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,503.30
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$7,817.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,754.94
|
| Rate for Payer: Health EOS Commercial |
$7,562.15
|
| Rate for Payer: HFN Commercial |
$7,817.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,372.60
|
| Rate for Payer: Multiplan Commercial |
$6,797.44
|
| Rate for Payer: NAPHCARE Commercial |
$5,098.08
|
| Rate for Payer: Preferred Network Access Commercial |
$7,817.06
|
| Rate for Payer: Quartz Beloit One Network |
$4,163.43
|
| Rate for Payer: Quartz Commercial |
$5,522.92
|
| Rate for Payer: Quartz Medicare Advantage |
$5,098.08
|
| Rate for Payer: The Alliance Commercial |
$4,248.40
|
| Rate for Payer: WEA Trust Commercial |
$4,673.24
|
| Rate for Payer: WPS Commercial |
$6,293.35
|
|
|
TIBIAL PLATE SIZE 3 5980-37-01
|
Facility
|
IP
|
$8,170.00
|
|
| Hospital Charge Code |
2967758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,163.43 |
| Max. Negotiated Rate |
$7,817.06 |
| Rate for Payer: Aetna Commercial |
$7,647.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,307.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,503.30
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$7,817.06
|
| Rate for Payer: Health EOS Commercial |
$7,562.15
|
| Rate for Payer: HFN Commercial |
$7,817.06
|
| Rate for Payer: Multiplan Commercial |
$6,797.44
|
| Rate for Payer: Preferred Network Access Commercial |
$7,817.06
|
| Rate for Payer: Quartz Beloit One Network |
$4,163.43
|
| Rate for Payer: Quartz Commercial |
$5,098.08
|
| Rate for Payer: WEA Trust Commercial |
$4,673.24
|
| Rate for Payer: WPS Commercial |
$6,293.35
|
|
|
TIBIAL PLATE SIZE 3 LEFT 71420164
|
Facility
|
OP
|
$18,121.00
|
|
| Hospital Charge Code |
2966054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,276.84 |
| Max. Negotiated Rate |
$17,338.17 |
| Rate for Payer: Aetna Commercial |
$16,961.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,207.42
|
| Rate for Payer: Aetna Managed Medicare |
$5,276.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,249.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,422.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,046.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,988.30
|
| Rate for Payer: Cash Price |
$5,436.30
|
| Rate for Payer: Cigna Commercial |
$17,338.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,546.42
|
| Rate for Payer: Health EOS Commercial |
$16,772.80
|
| Rate for Payer: HFN Commercial |
$17,338.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,134.38
|
| Rate for Payer: Multiplan Commercial |
$15,076.67
|
| Rate for Payer: NAPHCARE Commercial |
$11,307.50
|
| Rate for Payer: Preferred Network Access Commercial |
$17,338.17
|
| Rate for Payer: Quartz Beloit One Network |
$9,234.46
|
| Rate for Payer: Quartz Commercial |
$12,249.80
|
| Rate for Payer: Quartz Medicare Advantage |
$11,307.50
|
| Rate for Payer: The Alliance Commercial |
$9,422.92
|
| Rate for Payer: WEA Trust Commercial |
$10,365.21
|
| Rate for Payer: WPS Commercial |
$13,958.61
|
|
|
TIBIAL PLATE SIZE 3 LEFT 71420164
|
Facility
|
IP
|
$18,121.00
|
|
| Hospital Charge Code |
2966054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,234.46 |
| Max. Negotiated Rate |
$17,338.17 |
| Rate for Payer: Aetna Commercial |
$16,961.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,207.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,988.30
|
| Rate for Payer: Cash Price |
$5,436.30
|
| Rate for Payer: Cigna Commercial |
$17,338.17
|
| Rate for Payer: Health EOS Commercial |
$16,772.80
|
| Rate for Payer: HFN Commercial |
$17,338.17
|
| Rate for Payer: Multiplan Commercial |
$15,076.67
|
| Rate for Payer: Preferred Network Access Commercial |
$17,338.17
|
| Rate for Payer: Quartz Beloit One Network |
$9,234.46
|
| Rate for Payer: Quartz Commercial |
$11,307.50
|
| Rate for Payer: WEA Trust Commercial |
$10,365.21
|
| Rate for Payer: WPS Commercial |
$13,958.61
|
|
|
TIBIAL PLATE SZ 4 5980-37-02
|
Facility
|
OP
|
$8,170.00
|
|
| Hospital Charge Code |
2967759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,379.10 |
| Max. Negotiated Rate |
$7,817.06 |
| Rate for Payer: Aetna Commercial |
$7,647.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,307.25
|
| Rate for Payer: Aetna Managed Medicare |
$2,379.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,522.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,248.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,078.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,503.30
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$7,817.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,754.94
|
| Rate for Payer: Health EOS Commercial |
$7,562.15
|
| Rate for Payer: HFN Commercial |
$7,817.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,372.60
|
| Rate for Payer: Multiplan Commercial |
$6,797.44
|
| Rate for Payer: NAPHCARE Commercial |
$5,098.08
|
| Rate for Payer: Preferred Network Access Commercial |
$7,817.06
|
| Rate for Payer: Quartz Beloit One Network |
$4,163.43
|
| Rate for Payer: Quartz Commercial |
$5,522.92
|
| Rate for Payer: Quartz Medicare Advantage |
$5,098.08
|
| Rate for Payer: The Alliance Commercial |
$4,248.40
|
| Rate for Payer: WEA Trust Commercial |
$4,673.24
|
| Rate for Payer: WPS Commercial |
$6,293.35
|
|
|
TIBIAL PLATE SZ 4 5980-37-02
|
Facility
|
IP
|
$8,170.00
|
|
| Hospital Charge Code |
2967759
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,163.43 |
| Max. Negotiated Rate |
$7,817.06 |
| Rate for Payer: Aetna Commercial |
$7,647.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,307.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,503.30
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$7,817.06
|
| Rate for Payer: Health EOS Commercial |
$7,562.15
|
| Rate for Payer: HFN Commercial |
$7,817.06
|
| Rate for Payer: Multiplan Commercial |
$6,797.44
|
| Rate for Payer: Preferred Network Access Commercial |
$7,817.06
|
| Rate for Payer: Quartz Beloit One Network |
$4,163.43
|
| Rate for Payer: Quartz Commercial |
$5,098.08
|
| Rate for Payer: WEA Trust Commercial |
$4,673.24
|
| Rate for Payer: WPS Commercial |
$6,293.35
|
|
|
TIBIAL PLATE SZ 5 00-5980-047-01
|
Facility
|
IP
|
$7,868.00
|
|
| Hospital Charge Code |
2967760
|
|
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 PLATE SZ 5 00-5980-047-01
|
Facility
|
OP
|
$7,868.00
|
|
| Hospital Charge Code |
2967760
|
|
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
|
|
