|
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 |
$3,959.20 |
| Max. Negotiated Rate |
$7,433.60 |
| Rate for Payer: Aetna Commercial |
$7,272.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,948.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,282.40
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,433.60
|
| Rate for Payer: Health EOS Commercial |
$7,191.20
|
| Rate for Payer: HFN Commercial |
$7,433.60
|
| Rate for Payer: Multiplan Commercial |
$6,464.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,433.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,959.20
|
| Rate for Payer: Quartz Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$4,444.00
|
| Rate for Payer: WPS Commercial |
$5,984.86
|
|
|
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 |
$2,262.40 |
| Max. Negotiated Rate |
$32,320.00 |
| Rate for Payer: Aetna Commercial |
$7,272.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,948.80
|
| Rate for Payer: Aetna Managed Medicare |
$2,262.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,252.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,040.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,878.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,282.40
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,433.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,521.57
|
| Rate for Payer: Health EOS Commercial |
$7,191.20
|
| Rate for Payer: HFN Commercial |
$7,433.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,060.00
|
| Rate for Payer: Multiplan Commercial |
$6,464.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,433.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,959.20
|
| Rate for Payer: Quartz Commercial |
$5,252.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,848.00
|
| Rate for Payer: The Alliance Commercial |
$32,320.00
|
| Rate for Payer: WEA Trust Commercial |
$4,444.00
|
| Rate for Payer: WPS Commercial |
$5,984.86
|
|
|
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 |
$2,262.40 |
| Max. Negotiated Rate |
$32,320.00 |
| Rate for Payer: Aetna Commercial |
$7,272.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,948.80
|
| Rate for Payer: Aetna Managed Medicare |
$2,262.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,252.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,040.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,878.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,282.40
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,433.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,521.57
|
| Rate for Payer: Health EOS Commercial |
$7,191.20
|
| Rate for Payer: HFN Commercial |
$7,433.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,060.00
|
| Rate for Payer: Multiplan Commercial |
$6,464.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,433.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,959.20
|
| Rate for Payer: Quartz Commercial |
$5,252.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,848.00
|
| Rate for Payer: The Alliance Commercial |
$32,320.00
|
| Rate for Payer: WEA Trust Commercial |
$4,444.00
|
| Rate for Payer: WPS Commercial |
$5,984.86
|
|
|
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 |
$3,959.20 |
| Max. Negotiated Rate |
$7,433.60 |
| Rate for Payer: Aetna Commercial |
$7,272.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,948.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,282.40
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,433.60
|
| Rate for Payer: Health EOS Commercial |
$7,191.20
|
| Rate for Payer: HFN Commercial |
$7,433.60
|
| Rate for Payer: Multiplan Commercial |
$6,464.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,433.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,959.20
|
| Rate for Payer: Quartz Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$4,444.00
|
| Rate for Payer: WPS Commercial |
$5,984.86
|
|
|
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 |
$2,262.40 |
| Max. Negotiated Rate |
$32,320.00 |
| Rate for Payer: Aetna Commercial |
$7,272.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,948.80
|
| Rate for Payer: Aetna Managed Medicare |
$2,262.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,252.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,040.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,878.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,282.40
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,433.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,521.57
|
| Rate for Payer: Health EOS Commercial |
$7,191.20
|
| Rate for Payer: HFN Commercial |
$7,433.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,060.00
|
| Rate for Payer: Multiplan Commercial |
$6,464.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,433.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,959.20
|
| Rate for Payer: Quartz Commercial |
$5,252.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,848.00
|
| Rate for Payer: The Alliance Commercial |
$32,320.00
|
| Rate for Payer: WEA Trust Commercial |
$4,444.00
|
| Rate for Payer: WPS Commercial |
$5,984.86
|
|
|
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 |
$3,959.20 |
| Max. Negotiated Rate |
$7,433.60 |
| Rate for Payer: Aetna Commercial |
$7,272.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,948.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,282.40
|
| Rate for Payer: Cash Price |
$2,424.00
|
| Rate for Payer: Cigna Commercial |
$7,433.60
|
| Rate for Payer: Health EOS Commercial |
$7,191.20
|
| Rate for Payer: HFN Commercial |
$7,433.60
|
| Rate for Payer: Multiplan Commercial |
$6,464.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,433.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,959.20
|
| Rate for Payer: Quartz Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$4,444.00
|
| Rate for Payer: WPS Commercial |
$5,984.86
|
|
|
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 |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL 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 |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BLOCK SZ 4 5MM THICK 5988-04-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BLOCK SZ 4 5MM THICK 5988-04-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BLOCK SZ 5 5MM THICK 5988-05-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2973967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BLOCK SZ 5 5MM THICK 5988-05-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2973967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BLOCK SZ 6 5MM THICK 5988-06-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BLOCK SZ 6 5MM THICK 5988-06-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BLOCK SZ 7 5MM THICK 5988-07-26
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974037
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.80 |
| Max. Negotiated Rate |
$32,640.00 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,284.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,916.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,566.34
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,120.00
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$5,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,896.00
|
| Rate for Payer: The Alliance Commercial |
$32,640.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BLOCK SZ 7 5MM THICK 5988-07-26
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974037
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,998.40 |
| Max. Negotiated Rate |
$7,507.20 |
| Rate for Payer: Aetna Commercial |
$7,344.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,017.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,324.80
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,507.20
|
| Rate for Payer: Health EOS Commercial |
$7,262.40
|
| Rate for Payer: HFN Commercial |
$7,507.20
|
| Rate for Payer: Multiplan Commercial |
$6,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,896.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,507.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,998.40
|
| Rate for Payer: Quartz Commercial |
$4,896.00
|
| Rate for Payer: WEA Trust Commercial |
$4,488.00
|
| Rate for Payer: WPS Commercial |
$6,044.11
|
|
|
TIBIAL BONE GRAFTING
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2959866
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
TIBIAL BONE GRAFTING
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2959866
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
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 |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
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 |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL COMPONENT P.F.C. SIGMA ALL POLY CURVE SZ 4 10MM CEMENTED 96-0651
|
Facility
|
IP
|
$7,868.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5803650
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,855.32 |
| Max. Negotiated Rate |
$7,238.56 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$4,720.80
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL COMPONENT P.F.C. SIGMA ALL POLY CURVE SZ 4 10MM CEMENTED 96-0651
|
Facility
|
OP
|
$7,868.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5803650
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,203.04 |
| Max. Negotiated Rate |
$31,472.00 |
| Rate for Payer: Aetna Commercial |
$7,081.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,766.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,203.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,114.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,776.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,170.04
|
| Rate for Payer: Cash Price |
$2,360.40
|
| Rate for Payer: Cigna Commercial |
$7,238.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,402.93
|
| Rate for Payer: Health EOS Commercial |
$7,002.52
|
| Rate for Payer: HFN Commercial |
$7,238.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,901.00
|
| Rate for Payer: Multiplan Commercial |
$6,294.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,720.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,238.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,855.32
|
| Rate for Payer: Quartz Commercial |
$5,114.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,720.80
|
| Rate for Payer: The Alliance Commercial |
$31,472.00
|
| Rate for Payer: WEA Trust Commercial |
$4,327.40
|
| Rate for Payer: WPS Commercial |
$5,827.83
|
|
|
TIBIAL INSERT HINGE UNIVERSAL XSMALL 16MM LPS 1987-27-116
|
Facility
|
IP
|
$22,992.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,266.08 |
| Max. Negotiated Rate |
$21,152.64 |
| Rate for Payer: Aetna Commercial |
$20,692.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,773.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,185.76
|
| Rate for Payer: Cash Price |
$6,897.60
|
| Rate for Payer: Cigna Commercial |
$21,152.64
|
| Rate for Payer: Health EOS Commercial |
$20,462.88
|
| Rate for Payer: HFN Commercial |
$21,152.64
|
| Rate for Payer: Multiplan Commercial |
$18,393.60
|
| Rate for Payer: NAPHCARE Commercial |
$13,795.20
|
| Rate for Payer: Preferred Network Access Commercial |
$21,152.64
|
| Rate for Payer: Quartz Beloit One Network |
$11,266.08
|
| Rate for Payer: Quartz Commercial |
$13,795.20
|
| Rate for Payer: WEA Trust Commercial |
$12,645.60
|
| Rate for Payer: WPS Commercial |
$17,030.17
|
|
|
TIBIAL INSERT HINGE UNIVERSAL XSMALL 16MM LPS 1987-27-116
|
Facility
|
OP
|
$22,992.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,437.76 |
| Max. Negotiated Rate |
$91,968.00 |
| Rate for Payer: Aetna Commercial |
$20,692.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,773.12
|
| Rate for Payer: Aetna Managed Medicare |
$6,437.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,944.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,496.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,036.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,185.76
|
| Rate for Payer: Cash Price |
$6,897.60
|
| Rate for Payer: Cigna Commercial |
$21,152.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,866.32
|
| Rate for Payer: Health EOS Commercial |
$20,462.88
|
| Rate for Payer: HFN Commercial |
$21,152.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,244.00
|
| Rate for Payer: Multiplan Commercial |
$18,393.60
|
| Rate for Payer: NAPHCARE Commercial |
$13,795.20
|
| Rate for Payer: Preferred Network Access Commercial |
$21,152.64
|
| Rate for Payer: Quartz Beloit One Network |
$11,266.08
|
| Rate for Payer: Quartz Commercial |
$14,944.80
|
| Rate for Payer: Quartz Medicare Advantage |
$13,795.20
|
| Rate for Payer: The Alliance Commercial |
$91,968.00
|
| Rate for Payer: WEA Trust Commercial |
$12,645.60
|
| Rate for Payer: WPS Commercial |
$17,030.17
|
|
|
TIBIAL INSERT ROTATING PLATFORM PS ATTUNE SZ 10 5MM 1516-51-005
|
Facility
|
IP
|
$5,778.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6166146
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,831.22 |
| Max. Negotiated Rate |
$5,315.76 |
| Rate for Payer: Aetna Commercial |
$5,200.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,969.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,062.34
|
| Rate for Payer: Cash Price |
$1,733.40
|
| Rate for Payer: Cigna Commercial |
$5,315.76
|
| Rate for Payer: Health EOS Commercial |
$5,142.42
|
| Rate for Payer: HFN Commercial |
$5,315.76
|
| Rate for Payer: Multiplan Commercial |
$4,622.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,466.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,315.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,831.22
|
| Rate for Payer: Quartz Commercial |
$3,466.80
|
| Rate for Payer: WEA Trust Commercial |
$3,177.90
|
| Rate for Payer: WPS Commercial |
$4,279.76
|
|
