|
INSERT TRIATHLON TIBIAL BEARING CS SZ 2 9MM 5531-G-209
|
Facility
|
IP
|
$6,708.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3177477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 11MM 5531-G-311
|
Facility
|
IP
|
$6,967.00
|
|
| Hospital Charge Code |
4493889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,413.83 |
| Max. Negotiated Rate |
$6,409.64 |
| Rate for Payer: Aetna Commercial |
$6,270.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,991.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,692.51
|
| Rate for Payer: Cash Price |
$2,090.10
|
| Rate for Payer: Cigna Commercial |
$6,409.64
|
| Rate for Payer: Health EOS Commercial |
$6,200.63
|
| Rate for Payer: HFN Commercial |
$6,409.64
|
| Rate for Payer: Multiplan Commercial |
$5,573.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,180.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,409.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,413.83
|
| Rate for Payer: Quartz Commercial |
$4,180.20
|
| Rate for Payer: WEA Trust Commercial |
$3,831.85
|
| Rate for Payer: WPS Commercial |
$5,160.46
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 11MM 5531-G-311
|
Facility
|
OP
|
$6,967.00
|
|
| Hospital Charge Code |
4493889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.76 |
| Max. Negotiated Rate |
$27,868.00 |
| Rate for Payer: Aetna Commercial |
$6,270.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,991.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,950.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,528.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,483.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,344.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,692.51
|
| Rate for Payer: Cash Price |
$2,090.10
|
| Rate for Payer: Cigna Commercial |
$6,409.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,898.73
|
| Rate for Payer: Health EOS Commercial |
$6,200.63
|
| Rate for Payer: HFN Commercial |
$6,409.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,225.25
|
| Rate for Payer: Multiplan Commercial |
$5,573.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,180.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,409.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,413.83
|
| Rate for Payer: Quartz Commercial |
$4,528.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,180.20
|
| Rate for Payer: The Alliance Commercial |
$27,868.00
|
| Rate for Payer: WEA Trust Commercial |
$3,831.85
|
| Rate for Payer: WPS Commercial |
$5,160.46
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 13MM 5531-G-313
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
3444850
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 13MM 5531-G-313
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
3444850
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 16MM 5531-G-316
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
3789652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 16MM 5531-G-316
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
3789652
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 19MM 5531-G-319
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
4493890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 19MM 5531-G-319
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
4493890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 22MM 5531-G-322
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
4518619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 22MM 5531-G-322
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
4518619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 25MM 5531-G-325
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
4518620
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 25MM 5531-G-325
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
4518620
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 9MM 5531-G-309
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
3128847
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 3 9MM 5531-G-309
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
3128847
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 11MM 5531-G-411
|
Facility
|
OP
|
$6,967.00
|
|
| Hospital Charge Code |
4099058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.76 |
| Max. Negotiated Rate |
$27,868.00 |
| Rate for Payer: Aetna Commercial |
$6,270.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,991.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,950.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,528.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,483.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,344.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,692.51
|
| Rate for Payer: Cash Price |
$2,090.10
|
| Rate for Payer: Cigna Commercial |
$6,409.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,898.73
|
| Rate for Payer: Health EOS Commercial |
$6,200.63
|
| Rate for Payer: HFN Commercial |
$6,409.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,225.25
|
| Rate for Payer: Multiplan Commercial |
$5,573.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,180.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,409.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,413.83
|
| Rate for Payer: Quartz Commercial |
$4,528.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,180.20
|
| Rate for Payer: The Alliance Commercial |
$27,868.00
|
| Rate for Payer: WEA Trust Commercial |
$3,831.85
|
| Rate for Payer: WPS Commercial |
$5,160.46
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 11MM 5531-G-411
|
Facility
|
IP
|
$6,967.00
|
|
| Hospital Charge Code |
4099058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,413.83 |
| Max. Negotiated Rate |
$6,409.64 |
| Rate for Payer: Aetna Commercial |
$6,270.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,991.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,692.51
|
| Rate for Payer: Cash Price |
$2,090.10
|
| Rate for Payer: Cigna Commercial |
$6,409.64
|
| Rate for Payer: Health EOS Commercial |
$6,200.63
|
| Rate for Payer: HFN Commercial |
$6,409.64
|
| Rate for Payer: Multiplan Commercial |
$5,573.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,180.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,409.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,413.83
|
| Rate for Payer: Quartz Commercial |
$4,180.20
|
| Rate for Payer: WEA Trust Commercial |
$3,831.85
|
| Rate for Payer: WPS Commercial |
$5,160.46
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 16MM 5531-G-416
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
4206014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 16MM 5531-G-416
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
4206014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 19MM 5531-G-419
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
4493891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 19MM 5531-G-419
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
4493891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 22MM 5531-G-422
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
4493834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 22MM 5531-G-422
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
4493834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 25MM 5531-G-425
|
Facility
|
IP
|
$6,708.00
|
|
| Hospital Charge Code |
4518621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
|
INSERT TRIATHLON TIBIAL BEARING CS SZ 4 25MM 5531-G-425
|
Facility
|
OP
|
$6,708.00
|
|
| Hospital Charge Code |
4518621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$26,832.00 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$2,012.40
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.80
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$26,832.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.62
|
|
