|
Peritoneal Cath
|
Facility
|
OP
|
$2,790.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
5364787
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$781.20 |
| Max. Negotiated Rate |
$11,160.00 |
| Rate for Payer: Aetna Commercial |
$2,511.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,399.40
|
| Rate for Payer: Aetna Managed Medicare |
$781.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,813.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,395.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,339.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,478.70
|
| Rate for Payer: Cash Price |
$837.00
|
| Rate for Payer: Cigna Commercial |
$2,566.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,561.28
|
| Rate for Payer: Health EOS Commercial |
$2,483.10
|
| Rate for Payer: HFN Commercial |
$2,566.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,092.50
|
| Rate for Payer: Multiplan Commercial |
$2,232.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,674.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,566.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,367.10
|
| Rate for Payer: Quartz Commercial |
$1,813.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,674.00
|
| Rate for Payer: The Alliance Commercial |
$11,160.00
|
| Rate for Payer: WEA Trust Commercial |
$1,534.50
|
| Rate for Payer: WPS Commercial |
$2,066.55
|
|
|
Peritoneal Cath
|
Professional
|
Both
|
$2,790.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
5364787
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$1,227.60 |
| Max. Negotiated Rate |
$2,650.50 |
| Rate for Payer: Aetna Commercial |
$2,650.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,399.40
|
| Rate for Payer: Cash Price |
$837.00
|
| Rate for Payer: Cigna Commercial |
$2,650.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,395.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,674.00
|
| Rate for Payer: Health EOS Commercial |
$2,538.90
|
| Rate for Payer: HFN Commercial |
$2,650.50
|
| Rate for Payer: Multiplan Commercial |
$2,232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,650.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,227.60
|
| Rate for Payer: Quartz Commercial |
$1,590.30
|
| Rate for Payer: The Alliance Commercial |
$1,395.00
|
| Rate for Payer: WEA Trust Commercial |
$1,534.50
|
| Rate for Payer: WPS Commercial |
$2,066.55
|
|
|
Peritoneal Cath
|
Facility
|
IP
|
$2,790.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
5364787
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$1,367.10 |
| Max. Negotiated Rate |
$2,566.80 |
| Rate for Payer: Aetna Commercial |
$2,511.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,399.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,478.70
|
| Rate for Payer: Cash Price |
$837.00
|
| Rate for Payer: Cigna Commercial |
$2,566.80
|
| Rate for Payer: Health EOS Commercial |
$2,483.10
|
| Rate for Payer: HFN Commercial |
$2,566.80
|
| Rate for Payer: Multiplan Commercial |
$2,232.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,674.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,566.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,367.10
|
| Rate for Payer: Quartz Commercial |
$1,674.00
|
| Rate for Payer: WEA Trust Commercial |
$1,534.50
|
| Rate for Payer: WPS Commercial |
$2,066.55
|
|
|
Peritoneal Dial Insertion Kit
|
Facility
|
OP
|
$1,838.00
|
|
| Hospital Charge Code |
3603568
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$514.64 |
| Max. Negotiated Rate |
$7,352.00 |
| Rate for Payer: Aetna Commercial |
$1,654.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,580.68
|
| Rate for Payer: Aetna Managed Medicare |
$514.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,194.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$919.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$882.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.14
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Cigna Commercial |
$1,690.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,028.54
|
| Rate for Payer: Health EOS Commercial |
$1,635.82
|
| Rate for Payer: HFN Commercial |
$1,690.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,378.50
|
| Rate for Payer: Multiplan Commercial |
$1,470.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,102.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,690.96
|
| Rate for Payer: Quartz Beloit One Network |
$900.62
|
| Rate for Payer: Quartz Commercial |
$1,194.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,102.80
|
| Rate for Payer: The Alliance Commercial |
$7,352.00
|
| Rate for Payer: WEA Trust Commercial |
$1,010.90
|
| Rate for Payer: WPS Commercial |
$1,361.41
|
|
|
Peritoneal Dial Insertion Kit
|
Facility
|
IP
|
$1,838.00
|
|
| Hospital Charge Code |
3603568
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$900.62 |
| Max. Negotiated Rate |
$1,690.96 |
| Rate for Payer: Aetna Commercial |
$1,654.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,580.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.14
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Cigna Commercial |
$1,690.96
|
| Rate for Payer: Health EOS Commercial |
$1,635.82
|
| Rate for Payer: HFN Commercial |
$1,690.96
|
| Rate for Payer: Multiplan Commercial |
$1,470.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,102.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,690.96
|
| Rate for Payer: Quartz Beloit One Network |
$900.62
|
| Rate for Payer: Quartz Commercial |
$1,102.80
|
| Rate for Payer: WEA Trust Commercial |
$1,010.90
|
| Rate for Payer: WPS Commercial |
$1,361.41
|
|
|
PERITONEAL LAVAGE W/WO IMAGING GUIDANCE - UNLISTED LAPS 49329-49084
|
Professional
|
Both
|
$670.00
|
|
|
Service Code
|
CPT 49329
|
| Hospital Charge Code |
6178394
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$294.80 |
| Max. Negotiated Rate |
$636.50 |
| Rate for Payer: Aetna Commercial |
$636.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$576.20
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$636.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$335.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$402.00
|
| Rate for Payer: Health EOS Commercial |
$609.70
|
| Rate for Payer: HFN Commercial |
$636.50
|
| Rate for Payer: Multiplan Commercial |
$536.00
|
| Rate for Payer: Preferred Network Access Commercial |
$636.50
|
| Rate for Payer: Quartz Beloit One Network |
$294.80
|
| Rate for Payer: Quartz Commercial |
$381.90
|
| Rate for Payer: The Alliance Commercial |
$335.00
|
| Rate for Payer: WEA Trust Commercial |
$368.50
|
| Rate for Payer: WPS Commercial |
$496.27
|
|
|
Perivac Kit
|
Facility
|
IP
|
$2,004.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
4538649
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$981.96 |
| Max. Negotiated Rate |
$1,843.68 |
| Rate for Payer: Aetna Commercial |
$1,803.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,723.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.12
|
| Rate for Payer: Cash Price |
$601.20
|
| Rate for Payer: Cigna Commercial |
$1,843.68
|
| Rate for Payer: Health EOS Commercial |
$1,783.56
|
| Rate for Payer: HFN Commercial |
$1,843.68
|
| Rate for Payer: Multiplan Commercial |
$1,603.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,202.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,843.68
|
| Rate for Payer: Quartz Beloit One Network |
$981.96
|
| Rate for Payer: Quartz Commercial |
$1,202.40
|
| Rate for Payer: WEA Trust Commercial |
$1,102.20
|
| Rate for Payer: WPS Commercial |
$1,484.36
|
|
|
Perivac Kit
|
Facility
|
OP
|
$2,004.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
4538649
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.12 |
| Max. Negotiated Rate |
$8,016.00 |
| Rate for Payer: Aetna Commercial |
$1,803.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,723.44
|
| Rate for Payer: Aetna Managed Medicare |
$561.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,302.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$961.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.12
|
| Rate for Payer: Cash Price |
$601.20
|
| Rate for Payer: Cigna Commercial |
$1,843.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,121.44
|
| Rate for Payer: Health EOS Commercial |
$1,783.56
|
| Rate for Payer: HFN Commercial |
$1,843.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.00
|
| Rate for Payer: Multiplan Commercial |
$1,603.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,202.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,843.68
|
| Rate for Payer: Quartz Beloit One Network |
$981.96
|
| Rate for Payer: Quartz Commercial |
$1,302.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,202.40
|
| Rate for Payer: The Alliance Commercial |
$8,016.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.20
|
| Rate for Payer: WPS Commercial |
$1,484.36
|
|
|
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC
|
Facility
|
IP
|
$60,873.00
|
|
|
Service Code
|
MSDRG 243
|
| Min. Negotiated Rate |
$21,896.63 |
| Max. Negotiated Rate |
$60,873.00 |
| Rate for Payer: Aetna Managed Medicare |
$21,896.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47,834.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36,664.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34,833.84
|
| Rate for Payer: Anthem Medicare Advantage |
$21,896.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21,896.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21,896.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21,896.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38,668.75
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21,896.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44,413.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21,896.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21,896.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21,896.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21,896.63
|
| Rate for Payer: NAPHCARE Commercial |
$32,844.94
|
| Rate for Payer: Quartz Medicare Advantage |
$21,896.63
|
| Rate for Payer: The Alliance Commercial |
$60,873.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21,896.63
|
| Rate for Payer: United Healthcare PPO |
$34,576.25
|
| Rate for Payer: Wellcare Medicare |
$21,896.63
|
|
|
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC
|
Facility
|
IP
|
$92,178.00
|
|
|
Service Code
|
MSDRG 242
|
| Min. Negotiated Rate |
$33,157.40 |
| Max. Negotiated Rate |
$92,178.00 |
| Rate for Payer: Aetna Managed Medicare |
$33,157.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72,590.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55,640.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52,861.88
|
| Rate for Payer: Anthem Medicare Advantage |
$33,157.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33,157.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33,157.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$33,157.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58,681.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$33,157.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67,374.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33,157.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33,157.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$33,157.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$33,157.40
|
| Rate for Payer: NAPHCARE Commercial |
$49,736.10
|
| Rate for Payer: Quartz Medicare Advantage |
$33,157.40
|
| Rate for Payer: The Alliance Commercial |
$92,178.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33,157.40
|
| Rate for Payer: United Healthcare PPO |
$52,451.87
|
| Rate for Payer: Wellcare Medicare |
$33,157.40
|
|
|
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$48,959.00
|
|
|
Service Code
|
MSDRG 244
|
| Min. Negotiated Rate |
$17,611.32 |
| Max. Negotiated Rate |
$48,959.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,611.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,393.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,428.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,958.74
|
| Rate for Payer: Anthem Medicare Advantage |
$17,611.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,611.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,611.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,611.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,036.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,611.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35,675.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,611.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,611.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,611.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,611.32
|
| Rate for Payer: NAPHCARE Commercial |
$26,416.98
|
| Rate for Payer: Quartz Medicare Advantage |
$17,611.32
|
| Rate for Payer: The Alliance Commercial |
$48,959.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,611.32
|
| Rate for Payer: United Healthcare PPO |
$27,773.64
|
| Rate for Payer: Wellcare Medicare |
$17,611.32
|
|
|
Permanent tear duct plug A4263
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
HCPCS A4263
|
| Hospital Charge Code |
3292171
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.52 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Aetna Commercial |
$150.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$150.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.80
|
| Rate for Payer: Health EOS Commercial |
$143.78
|
| Rate for Payer: HFN Commercial |
$150.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$92.84
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.10
|
| Rate for Payer: Quartz Beloit One Network |
$69.52
|
| Rate for Payer: Quartz Commercial |
$90.06
|
| Rate for Payer: The Alliance Commercial |
$79.00
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Permanent tear duct plug A4263
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
HCPCS A4263
|
| Hospital Charge Code |
3292171
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.24 |
| Max. Negotiated Rate |
$632.00 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Aetna Managed Medicare |
$44.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.42
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$118.50
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$102.70
|
| Rate for Payer: Quartz Medicare Advantage |
$94.80
|
| Rate for Payer: The Alliance Commercial |
$632.00
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Permanent tear duct plug A4263
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
HCPCS A4263
|
| Hospital Charge Code |
3292171
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.42 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$94.80
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Perq cervicothoracic inject 22510
|
Professional
|
Both
|
$4,259.00
|
|
|
Service Code
|
CPT 22510
|
| Hospital Charge Code |
6181378
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,342.87 |
| Max. Negotiated Rate |
$4,046.05 |
| Rate for Payer: Aetna Commercial |
$4,046.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,662.74
|
| Rate for Payer: Cash Price |
$1,277.70
|
| Rate for Payer: Cash Price |
$1,277.70
|
| Rate for Payer: Cash Price |
$1,277.70
|
| Rate for Payer: Cigna Commercial |
$4,046.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,342.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,555.40
|
| Rate for Payer: Health EOS Commercial |
$3,875.69
|
| Rate for Payer: HFN Commercial |
$4,046.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,438.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,438.90
|
| Rate for Payer: Multiplan Commercial |
$3,407.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,046.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,873.96
|
| Rate for Payer: Quartz Commercial |
$2,427.63
|
| Rate for Payer: The Alliance Commercial |
$2,129.50
|
| Rate for Payer: United Healthcare Medicaid |
$1,342.87
|
| Rate for Payer: WEA Trust Commercial |
$2,342.45
|
| Rate for Payer: WPS Commercial |
$3,154.64
|
|
|
Perq&ic allg test drugs/biol 95018
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
CPT 95018
|
| Hospital Charge Code |
3529576
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$7.26 |
| Max. Negotiated Rate |
$72.15 |
| Rate for Payer: Aetna Commercial |
$47.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$47.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.00
|
| Rate for Payer: Health EOS Commercial |
$45.50
|
| Rate for Payer: HFN Commercial |
$47.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.15
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: Preferred Network Access Commercial |
$47.50
|
| Rate for Payer: Quartz Beloit One Network |
$22.00
|
| Rate for Payer: Quartz Commercial |
$28.50
|
| Rate for Payer: The Alliance Commercial |
$25.00
|
| Rate for Payer: United Healthcare Medicaid |
$7.26
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
Perq sacral augmt bilat inj 0201T
|
Professional
|
Both
|
$4,503.00
|
|
|
Service Code
|
CPT 0201T
|
| Hospital Charge Code |
6181383
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,981.32 |
| Max. Negotiated Rate |
$6,426.22 |
| Rate for Payer: Aetna Commercial |
$4,277.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,872.58
|
| Rate for Payer: Cash Price |
$1,350.90
|
| Rate for Payer: Cash Price |
$1,350.90
|
| Rate for Payer: Cigna Commercial |
$4,277.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,251.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,701.80
|
| Rate for Payer: Health EOS Commercial |
$4,097.73
|
| Rate for Payer: HFN Commercial |
$4,277.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,426.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,426.22
|
| Rate for Payer: Multiplan Commercial |
$3,602.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,277.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,981.32
|
| Rate for Payer: Quartz Commercial |
$2,566.71
|
| Rate for Payer: The Alliance Commercial |
$2,251.50
|
| Rate for Payer: WEA Trust Commercial |
$2,476.65
|
| Rate for Payer: WPS Commercial |
$3,335.37
|
|
|
Perq sacral augmt unilat inj 0200T
|
Professional
|
Both
|
$3,441.00
|
|
|
Service Code
|
CPT 0200T
|
| Hospital Charge Code |
6181382
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,514.04 |
| Max. Negotiated Rate |
$6,426.22 |
| Rate for Payer: Aetna Commercial |
$3,268.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,959.26
|
| Rate for Payer: Cash Price |
$1,032.30
|
| Rate for Payer: Cash Price |
$1,032.30
|
| Rate for Payer: Cigna Commercial |
$3,268.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,720.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,064.60
|
| Rate for Payer: Health EOS Commercial |
$3,131.31
|
| Rate for Payer: HFN Commercial |
$3,268.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,426.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,426.22
|
| Rate for Payer: Multiplan Commercial |
$2,752.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,268.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,514.04
|
| Rate for Payer: Quartz Commercial |
$1,961.37
|
| Rate for Payer: The Alliance Commercial |
$1,720.50
|
| Rate for Payer: WEA Trust Commercial |
$1,892.55
|
| Rate for Payer: WPS Commercial |
$2,548.75
|
|
|
Perq vertebral augmentation Lumbar 22514
|
Professional
|
Both
|
$4,326.00
|
|
|
Service Code
|
CPT 22514
|
| Hospital Charge Code |
6181381
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,566.90 |
| Max. Negotiated Rate |
$5,632.80 |
| Rate for Payer: Aetna Commercial |
$4,109.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,720.36
|
| Rate for Payer: Cash Price |
$1,297.80
|
| Rate for Payer: Cash Price |
$1,297.80
|
| Rate for Payer: Cash Price |
$1,297.80
|
| Rate for Payer: Cigna Commercial |
$4,109.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,632.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,595.60
|
| Rate for Payer: Health EOS Commercial |
$3,936.66
|
| Rate for Payer: HFN Commercial |
$4,109.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,566.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,566.90
|
| Rate for Payer: Multiplan Commercial |
$3,460.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,109.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,903.44
|
| Rate for Payer: Quartz Commercial |
$2,465.82
|
| Rate for Payer: The Alliance Commercial |
$2,163.00
|
| Rate for Payer: United Healthcare Medicaid |
$5,632.80
|
| Rate for Payer: WEA Trust Commercial |
$2,379.30
|
| Rate for Payer: WPS Commercial |
$3,204.27
|
|
|
Perq vertebral augmentation Thoracic 22513
|
Professional
|
Both
|
$4,664.00
|
|
|
Service Code
|
CPT 22513
|
| Hospital Charge Code |
6181380
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,679.33 |
| Max. Negotiated Rate |
$5,654.38 |
| Rate for Payer: Aetna Commercial |
$4,430.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,011.04
|
| Rate for Payer: Cash Price |
$1,399.20
|
| Rate for Payer: Cash Price |
$1,399.20
|
| Rate for Payer: Cash Price |
$1,399.20
|
| Rate for Payer: Cigna Commercial |
$4,430.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,654.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,798.40
|
| Rate for Payer: Health EOS Commercial |
$4,244.24
|
| Rate for Payer: HFN Commercial |
$4,430.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,679.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,679.33
|
| Rate for Payer: Multiplan Commercial |
$3,731.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,430.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,052.16
|
| Rate for Payer: Quartz Commercial |
$2,658.48
|
| Rate for Payer: The Alliance Commercial |
$2,332.00
|
| Rate for Payer: United Healthcare Medicaid |
$5,654.38
|
| Rate for Payer: WEA Trust Commercial |
$2,565.20
|
| Rate for Payer: WPS Commercial |
$3,454.62
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 10MM 42-5224-004-10
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3583494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 10MM 42-5224-004-10
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3583494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 11MM 42-5224-004-11
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 11MM 42-5224-004-11
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 12MM 42-5224-004-12
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
