|
TIBIA PERSONA 5 DEG STEMMED LT SZ E 42-5320-071-01
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267497
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ E 42-5320-071-01
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267497
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ F 42-5320-075-01
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ F 42-5320-075-01
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ G 42-5320-079-01
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3727503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ G 42-5320-079-01
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3727503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ H 42-5320-083-01
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ H 42-5320-083-01
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ J 42-5320-088-01
|
Facility
|
IP
|
$6,558.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,341.96 |
| Max. Negotiated Rate |
$6,274.69 |
| Rate for Payer: Aetna Commercial |
$6,138.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,865.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,614.77
|
| Rate for Payer: Cash Price |
$1,967.40
|
| Rate for Payer: Cigna Commercial |
$6,274.69
|
| Rate for Payer: Health EOS Commercial |
$6,070.08
|
| Rate for Payer: HFN Commercial |
$6,274.69
|
| Rate for Payer: Multiplan Commercial |
$5,456.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,274.69
|
| Rate for Payer: Quartz Beloit One Network |
$3,341.96
|
| Rate for Payer: Quartz Commercial |
$4,092.19
|
| Rate for Payer: WEA Trust Commercial |
$3,751.18
|
| Rate for Payer: WPS Commercial |
$5,051.63
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ J 42-5320-088-01
|
Facility
|
OP
|
$6,558.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,909.69 |
| Max. Negotiated Rate |
$6,274.69 |
| Rate for Payer: Aetna Commercial |
$6,138.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,865.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,909.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,433.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,410.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,273.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,614.77
|
| Rate for Payer: Cash Price |
$1,967.40
|
| Rate for Payer: Cigna Commercial |
$6,274.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,816.76
|
| Rate for Payer: Health EOS Commercial |
$6,070.08
|
| Rate for Payer: HFN Commercial |
$6,274.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,115.24
|
| Rate for Payer: Multiplan Commercial |
$5,456.26
|
| Rate for Payer: NAPHCARE Commercial |
$4,092.19
|
| Rate for Payer: Preferred Network Access Commercial |
$6,274.69
|
| Rate for Payer: Quartz Beloit One Network |
$3,341.96
|
| Rate for Payer: Quartz Commercial |
$4,433.21
|
| Rate for Payer: Quartz Medicare Advantage |
$4,092.19
|
| Rate for Payer: The Alliance Commercial |
$3,410.16
|
| Rate for Payer: WEA Trust Commercial |
$3,751.18
|
| Rate for Payer: WPS Commercial |
$5,051.63
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ C 42-5320-064-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3333503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ C 42-5320-064-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3333503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ D 42-5320-067-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ D 42-5320-067-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ E 42-5320-071-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ E 42-5320-071-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ F 42-5320-075-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3381506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ F 42-5320-075-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3381506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ G 42-5320-079-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3116527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ G 42-5320-079-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3116527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ H 42-5320-083-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3739521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.44 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,222.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,159.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,968.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,809.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,441.82
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,952.96
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,762.37
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$5,159.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,762.37
|
| Rate for Payer: The Alliance Commercial |
$3,968.64
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ H 42-5320-083-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3739521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,889.27 |
| Max. Negotiated Rate |
$7,302.30 |
| Rate for Payer: Aetna Commercial |
$7,143.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,826.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,206.76
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,302.30
|
| Rate for Payer: Health EOS Commercial |
$7,064.18
|
| Rate for Payer: HFN Commercial |
$7,302.30
|
| Rate for Payer: Multiplan Commercial |
$6,349.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,302.30
|
| Rate for Payer: Quartz Beloit One Network |
$3,889.27
|
| Rate for Payer: Quartz Commercial |
$4,762.37
|
| Rate for Payer: WEA Trust Commercial |
$4,365.50
|
| Rate for Payer: WPS Commercial |
$5,878.93
|
|
|
TIBIA TRAY ZUK HIGH FLEX SZ 2 RT MED/LT LAT 5842-02-02
|
Facility
|
IP
|
$6,892.00
|
|
| Hospital Charge Code |
3241465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,512.16 |
| Max. Negotiated Rate |
$6,594.27 |
| Rate for Payer: Aetna Commercial |
$6,450.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,164.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,798.87
|
| Rate for Payer: Cash Price |
$2,067.60
|
| Rate for Payer: Cigna Commercial |
$6,594.27
|
| Rate for Payer: Health EOS Commercial |
$6,379.24
|
| Rate for Payer: HFN Commercial |
$6,594.27
|
| Rate for Payer: Multiplan Commercial |
$5,734.14
|
| Rate for Payer: Preferred Network Access Commercial |
$6,594.27
|
| Rate for Payer: Quartz Beloit One Network |
$3,512.16
|
| Rate for Payer: Quartz Commercial |
$4,300.61
|
| Rate for Payer: WEA Trust Commercial |
$3,942.22
|
| Rate for Payer: WPS Commercial |
$5,308.91
|
|
|
TIBIA TRAY ZUK HIGH FLEX SZ 2 RT MED/LT LAT 5842-02-02
|
Facility
|
OP
|
$6,892.00
|
|
| Hospital Charge Code |
3241465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,006.95 |
| Max. Negotiated Rate |
$6,594.27 |
| Rate for Payer: Aetna Commercial |
$6,450.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,164.20
|
| Rate for Payer: Aetna Managed Medicare |
$2,006.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,658.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,583.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,440.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,798.87
|
| Rate for Payer: Cash Price |
$2,067.60
|
| Rate for Payer: Cigna Commercial |
$6,594.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,011.14
|
| Rate for Payer: Health EOS Commercial |
$6,379.24
|
| Rate for Payer: HFN Commercial |
$6,594.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,375.76
|
| Rate for Payer: Multiplan Commercial |
$5,734.14
|
| Rate for Payer: NAPHCARE Commercial |
$4,300.61
|
| Rate for Payer: Preferred Network Access Commercial |
$6,594.27
|
| Rate for Payer: Quartz Beloit One Network |
$3,512.16
|
| Rate for Payer: Quartz Commercial |
$4,658.99
|
| Rate for Payer: Quartz Medicare Advantage |
$4,300.61
|
| Rate for Payer: The Alliance Commercial |
$3,583.84
|
| Rate for Payer: WEA Trust Commercial |
$3,942.22
|
| Rate for Payer: WPS Commercial |
$5,308.91
|
|
|
Tick and Arthropods ID
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
CPT 87168
|
| Hospital Charge Code |
4716606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$80.03 |
| Rate for Payer: Aetna Commercial |
$80.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$4.44
|
| Rate for Payer: Anthem Medicare Advantage |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.44
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$80.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.44
|
| Rate for Payer: Health EOS Commercial |
$76.66
|
| Rate for Payer: HFN Commercial |
$80.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$80.03
|
| Rate for Payer: Quartz Beloit One Network |
$37.07
|
| Rate for Payer: Quartz Commercial |
$48.02
|
| Rate for Payer: Quartz Medicare Advantage |
$4.44
|
| Rate for Payer: The Alliance Commercial |
$17.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.44
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$19.54
|
|
