|
TIBIAL TRAY OXFORD LT MEDIAL SZ D 154724
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5384758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.15 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,736.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.49
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.68
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,736.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.74
|
| Rate for Payer: The Alliance Commercial |
$3,643.12
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ E 154726
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,570.26 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,371.74
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY OXFORD LT MEDIAL SZ E 154726
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.15 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,736.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.49
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.68
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,736.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.74
|
| Rate for Payer: The Alliance Commercial |
$3,643.12
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ B 154721
|
Facility
|
IP
|
$7,286.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,712.95 |
| Max. Negotiated Rate |
$6,971.24 |
| Rate for Payer: Aetna Commercial |
$6,819.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,516.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,016.04
|
| Rate for Payer: Cash Price |
$2,185.80
|
| Rate for Payer: Cigna Commercial |
$6,971.24
|
| Rate for Payer: Health EOS Commercial |
$6,743.92
|
| Rate for Payer: HFN Commercial |
$6,971.24
|
| Rate for Payer: Multiplan Commercial |
$6,061.95
|
| Rate for Payer: Preferred Network Access Commercial |
$6,971.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,712.95
|
| Rate for Payer: Quartz Commercial |
$4,546.46
|
| Rate for Payer: WEA Trust Commercial |
$4,167.59
|
| Rate for Payer: WPS Commercial |
$5,612.41
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ B 154721
|
Facility
|
OP
|
$7,286.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,121.68 |
| Max. Negotiated Rate |
$6,971.24 |
| Rate for Payer: Aetna Commercial |
$6,819.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,516.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,121.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,925.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,788.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,637.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,016.04
|
| Rate for Payer: Cash Price |
$2,185.80
|
| Rate for Payer: Cigna Commercial |
$6,971.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,240.45
|
| Rate for Payer: Health EOS Commercial |
$6,743.92
|
| Rate for Payer: HFN Commercial |
$6,971.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,683.08
|
| Rate for Payer: Multiplan Commercial |
$6,061.95
|
| Rate for Payer: NAPHCARE Commercial |
$4,546.46
|
| Rate for Payer: Preferred Network Access Commercial |
$6,971.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,712.95
|
| Rate for Payer: Quartz Commercial |
$4,925.34
|
| Rate for Payer: Quartz Medicare Advantage |
$4,546.46
|
| Rate for Payer: The Alliance Commercial |
$3,788.72
|
| Rate for Payer: WEA Trust Commercial |
$4,167.59
|
| Rate for Payer: WPS Commercial |
$5,612.41
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ C 154723
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.15 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,736.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.49
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.68
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,736.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.74
|
| Rate for Payer: The Alliance Commercial |
$3,643.12
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ C 154723
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,570.26 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,371.74
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ D 154725
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5179208
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.15 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,736.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.49
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.68
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,736.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.74
|
| Rate for Payer: The Alliance Commercial |
$3,643.12
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ D 154725
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5179208
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,570.26 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,371.74
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ E 154727
|
Facility
|
OP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.15 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,736.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,643.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,497.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,077.49
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,464.68
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.74
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,736.06
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.74
|
| Rate for Payer: The Alliance Commercial |
$3,643.12
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY OXFORD RT MEDIAL SZ E 154727
|
Facility
|
IP
|
$7,006.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,570.26 |
| Max. Negotiated Rate |
$6,703.34 |
| Rate for Payer: Aetna Commercial |
$6,557.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,266.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.71
|
| Rate for Payer: Cash Price |
$2,101.80
|
| Rate for Payer: Cigna Commercial |
$6,703.34
|
| Rate for Payer: Health EOS Commercial |
$6,484.75
|
| Rate for Payer: HFN Commercial |
$6,703.34
|
| Rate for Payer: Multiplan Commercial |
$5,828.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,703.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,570.26
|
| Rate for Payer: Quartz Commercial |
$4,371.74
|
| Rate for Payer: WEA Trust Commercial |
$4,007.43
|
| Rate for Payer: WPS Commercial |
$5,396.72
|
|
|
TIBIAL TRAY ROTATING PLATFORM M.B.T. REVISION CEMENTED SZ 2.5 1294-35-125
|
Facility
|
OP
|
$35,435.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,318.67 |
| Max. Negotiated Rate |
$33,904.21 |
| Rate for Payer: Aetna Commercial |
$33,167.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31,693.06
|
| Rate for Payer: Aetna Managed Medicare |
$10,318.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,954.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,426.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,689.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,531.77
|
| Rate for Payer: Cash Price |
$10,630.50
|
| Rate for Payer: Cigna Commercial |
$33,904.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,623.17
|
| Rate for Payer: Health EOS Commercial |
$32,798.64
|
| Rate for Payer: HFN Commercial |
$33,904.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,639.30
|
| Rate for Payer: Multiplan Commercial |
$29,481.92
|
| Rate for Payer: NAPHCARE Commercial |
$22,111.44
|
| Rate for Payer: Preferred Network Access Commercial |
$33,904.21
|
| Rate for Payer: Quartz Beloit One Network |
$18,057.68
|
| Rate for Payer: Quartz Commercial |
$23,954.06
|
| Rate for Payer: Quartz Medicare Advantage |
$22,111.44
|
| Rate for Payer: The Alliance Commercial |
$18,426.20
|
| Rate for Payer: WEA Trust Commercial |
$20,268.82
|
| Rate for Payer: WPS Commercial |
$27,295.58
|
|
|
TIBIAL TRAY ROTATING PLATFORM M.B.T. REVISION CEMENTED SZ 2.5 1294-35-125
|
Facility
|
IP
|
$35,435.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$18,057.68 |
| Max. Negotiated Rate |
$33,904.21 |
| Rate for Payer: Aetna Commercial |
$33,167.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31,693.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,531.77
|
| Rate for Payer: Cash Price |
$10,630.50
|
| Rate for Payer: Cigna Commercial |
$33,904.21
|
| Rate for Payer: Health EOS Commercial |
$32,798.64
|
| Rate for Payer: HFN Commercial |
$33,904.21
|
| Rate for Payer: Multiplan Commercial |
$29,481.92
|
| Rate for Payer: Preferred Network Access Commercial |
$33,904.21
|
| Rate for Payer: Quartz Beloit One Network |
$18,057.68
|
| Rate for Payer: Quartz Commercial |
$22,111.44
|
| Rate for Payer: WEA Trust Commercial |
$20,268.82
|
| Rate for Payer: WPS Commercial |
$27,295.58
|
|
|
TIBIAL WEDGE HALF SZ 16 DEG 5988-05-20
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 16 DEG 5988-05-20
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 3 16 DEG 5988-03-20
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 3 16 DEG 5988-03-20
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 4 16 DEG 5988-04-20
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974032
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 4 16 DEG 5988-04-20
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974032
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 6 15 DEG 5988-06-20
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 6 15 DEG 5988-06-20
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 7 16 DEG 5988-07-20
|
Facility
|
IP
|
$8,160.00
|
|
| Hospital Charge Code |
2974036
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,158.34 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,091.84
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIAL WEDGE HALF SZ 7 16 DEG 5988-07-20
|
Facility
|
OP
|
$8,160.00
|
|
| Hospital Charge Code |
2974036
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,376.19 |
| Max. Negotiated Rate |
$7,807.49 |
| Rate for Payer: Aetna Commercial |
$7,637.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,298.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,376.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,516.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,243.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,073.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,497.79
|
| Rate for Payer: Cash Price |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$7,807.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,749.12
|
| Rate for Payer: Health EOS Commercial |
$7,552.90
|
| Rate for Payer: HFN Commercial |
$7,807.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,364.80
|
| Rate for Payer: Multiplan Commercial |
$6,789.12
|
| Rate for Payer: NAPHCARE Commercial |
$5,091.84
|
| Rate for Payer: Preferred Network Access Commercial |
$7,807.49
|
| Rate for Payer: Quartz Beloit One Network |
$4,158.34
|
| Rate for Payer: Quartz Commercial |
$5,516.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,091.84
|
| Rate for Payer: The Alliance Commercial |
$4,243.20
|
| Rate for Payer: WEA Trust Commercial |
$4,667.52
|
| Rate for Payer: WPS Commercial |
$6,285.65
|
|
|
TIBIA PERSONA 0 DEG NP KEL LT SZ G 42-5360-079-01
|
Facility
|
IP
|
$5,886.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,999.68 |
| Max. Negotiated Rate |
$5,632.06 |
| Rate for Payer: Aetna Commercial |
$5,509.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,264.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,244.56
|
| Rate for Payer: Cash Price |
$1,765.90
|
| Rate for Payer: Cigna Commercial |
$5,632.06
|
| Rate for Payer: Health EOS Commercial |
$5,448.41
|
| Rate for Payer: HFN Commercial |
$5,632.06
|
| Rate for Payer: Multiplan Commercial |
$4,897.44
|
| Rate for Payer: Preferred Network Access Commercial |
$5,632.06
|
| Rate for Payer: Quartz Beloit One Network |
$2,999.68
|
| Rate for Payer: Quartz Commercial |
$3,673.08
|
| Rate for Payer: WEA Trust Commercial |
$3,366.99
|
| Rate for Payer: WPS Commercial |
$4,534.26
|
|
|
TIBIA PERSONA 0 DEG NP KEL LT SZ G 42-5360-079-01
|
Facility
|
OP
|
$5,886.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,714.11 |
| Max. Negotiated Rate |
$5,632.06 |
| Rate for Payer: Aetna Commercial |
$5,509.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,264.75
|
| Rate for Payer: Aetna Managed Medicare |
$1,714.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,979.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,060.90
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,938.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,244.56
|
| Rate for Payer: Cash Price |
$1,765.90
|
| Rate for Payer: Cigna Commercial |
$5,632.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,425.86
|
| Rate for Payer: Health EOS Commercial |
$5,448.41
|
| Rate for Payer: HFN Commercial |
$5,632.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,591.35
|
| Rate for Payer: Multiplan Commercial |
$4,897.44
|
| Rate for Payer: NAPHCARE Commercial |
$3,673.08
|
| Rate for Payer: Preferred Network Access Commercial |
$5,632.06
|
| Rate for Payer: Quartz Beloit One Network |
$2,999.68
|
| Rate for Payer: Quartz Commercial |
$3,979.17
|
| Rate for Payer: Quartz Medicare Advantage |
$3,673.08
|
| Rate for Payer: The Alliance Commercial |
$3,060.90
|
| Rate for Payer: WEA Trust Commercial |
$3,366.99
|
| Rate for Payer: WPS Commercial |
$4,534.26
|
|
