|
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 |
$2,060.57 |
| Max. Negotiated Rate |
$6,683.27 |
| Rate for Payer: Aetna Commercial |
$4,448.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,027.48
|
| Rate for Payer: Cash Price |
$1,350.90
|
| Rate for Payer: Cash Price |
$1,350.90
|
| Rate for Payer: Cigna Commercial |
$4,448.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,341.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,809.87
|
| Rate for Payer: Health EOS Commercial |
$4,261.64
|
| Rate for Payer: HFN Commercial |
$4,448.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,683.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,683.27
|
| Rate for Payer: Multiplan Commercial |
$3,746.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,448.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,060.57
|
| Rate for Payer: Quartz Commercial |
$2,669.38
|
| Rate for Payer: The Alliance Commercial |
$2,341.56
|
| Rate for Payer: WEA Trust Commercial |
$2,575.72
|
| Rate for Payer: WPS Commercial |
$3,468.66
|
|
|
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 |
$1,574.60 |
| Max. Negotiated Rate |
$6,683.27 |
| Rate for Payer: Aetna Commercial |
$3,399.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,077.63
|
| Rate for Payer: Cash Price |
$1,032.30
|
| Rate for Payer: Cash Price |
$1,032.30
|
| Rate for Payer: Cigna Commercial |
$3,399.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,789.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,147.18
|
| Rate for Payer: Health EOS Commercial |
$3,256.56
|
| Rate for Payer: HFN Commercial |
$3,399.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,683.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,683.27
|
| Rate for Payer: Multiplan Commercial |
$2,862.91
|
| Rate for Payer: Preferred Network Access Commercial |
$3,399.71
|
| Rate for Payer: Quartz Beloit One Network |
$1,574.60
|
| Rate for Payer: Quartz Commercial |
$2,039.82
|
| Rate for Payer: The Alliance Commercial |
$1,789.32
|
| Rate for Payer: WEA Trust Commercial |
$1,968.25
|
| Rate for Payer: WPS Commercial |
$2,650.60
|
|
|
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 |
$401.48 |
| Max. Negotiated Rate |
$5,858.11 |
| Rate for Payer: Aetna Commercial |
$4,274.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,869.17
|
| Rate for Payer: Aetna Managed Medicare |
$401.48
|
| Rate for Payer: Anthem Medicare Advantage |
$401.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$401.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$401.48
|
| 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 |
$4,274.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,858.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$401.48
|
| Rate for Payer: Health EOS Commercial |
$4,094.13
|
| Rate for Payer: HFN Commercial |
$4,274.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,629.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,629.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$401.48
|
| Rate for Payer: Multiplan Commercial |
$3,599.23
|
| Rate for Payer: NAPHCARE Commercial |
$602.22
|
| Rate for Payer: Preferred Network Access Commercial |
$4,274.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,979.58
|
| Rate for Payer: Quartz Commercial |
$2,564.45
|
| Rate for Payer: Quartz Medicare Advantage |
$401.48
|
| Rate for Payer: The Alliance Commercial |
$1,706.30
|
| Rate for Payer: United Healthcare Medicaid |
$5,858.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$401.48
|
| Rate for Payer: WEA Trust Commercial |
$2,474.47
|
| Rate for Payer: WPS Commercial |
$1,806.67
|
|
|
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 |
$428.76 |
| Max. Negotiated Rate |
$5,880.56 |
| Rate for Payer: Aetna Commercial |
$4,608.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,171.48
|
| Rate for Payer: Aetna Managed Medicare |
$428.76
|
| Rate for Payer: Anthem Medicare Advantage |
$428.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$428.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$428.76
|
| 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 |
$4,608.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,880.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$428.76
|
| Rate for Payer: Health EOS Commercial |
$4,414.01
|
| Rate for Payer: HFN Commercial |
$4,608.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,746.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,746.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$428.76
|
| Rate for Payer: Multiplan Commercial |
$3,880.45
|
| Rate for Payer: NAPHCARE Commercial |
$643.14
|
| Rate for Payer: Preferred Network Access Commercial |
$4,608.03
|
| Rate for Payer: Quartz Beloit One Network |
$2,134.25
|
| Rate for Payer: Quartz Commercial |
$2,764.82
|
| Rate for Payer: Quartz Medicare Advantage |
$428.76
|
| Rate for Payer: The Alliance Commercial |
$1,822.23
|
| Rate for Payer: United Healthcare Medicaid |
$5,880.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$428.76
|
| Rate for Payer: WEA Trust Commercial |
$2,667.81
|
| Rate for Payer: WPS Commercial |
$1,929.42
|
|
|
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 |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
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 |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
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 |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
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 |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 12MM 42-5224-004-12
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
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 |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 13MM 42-5224-004-13
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 13MM 42-5224-004-13
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 14MM RT 42-5224-004-14
|
Facility
|
IP
|
$9,089.00
|
|
| Hospital Charge Code |
5286608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,631.75 |
| Max. Negotiated Rate |
$8,696.36 |
| Rate for Payer: Aetna Commercial |
$8,507.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,129.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.86
|
| Rate for Payer: Cash Price |
$2,726.70
|
| Rate for Payer: Cigna Commercial |
$8,696.36
|
| Rate for Payer: Health EOS Commercial |
$8,412.78
|
| Rate for Payer: HFN Commercial |
$8,696.36
|
| Rate for Payer: Multiplan Commercial |
$7,562.05
|
| Rate for Payer: Preferred Network Access Commercial |
$8,696.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.75
|
| Rate for Payer: Quartz Commercial |
$5,671.54
|
| Rate for Payer: WEA Trust Commercial |
$5,198.91
|
| Rate for Payer: WPS Commercial |
$7,001.26
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 14MM RT 42-5224-004-14
|
Facility
|
OP
|
$9,089.00
|
|
| Hospital Charge Code |
5286608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,646.72 |
| Max. Negotiated Rate |
$8,696.36 |
| Rate for Payer: Aetna Commercial |
$8,507.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,129.20
|
| Rate for Payer: Aetna Managed Medicare |
$2,646.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,144.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,726.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,537.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.86
|
| Rate for Payer: Cash Price |
$2,726.70
|
| Rate for Payer: Cigna Commercial |
$8,696.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,289.80
|
| Rate for Payer: Health EOS Commercial |
$8,412.78
|
| Rate for Payer: HFN Commercial |
$8,696.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,089.42
|
| Rate for Payer: Multiplan Commercial |
$7,562.05
|
| Rate for Payer: NAPHCARE Commercial |
$5,671.54
|
| Rate for Payer: Preferred Network Access Commercial |
$8,696.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.75
|
| Rate for Payer: Quartz Commercial |
$6,144.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,671.54
|
| Rate for Payer: The Alliance Commercial |
$4,726.28
|
| Rate for Payer: WEA Trust Commercial |
$5,198.91
|
| Rate for Payer: WPS Commercial |
$7,001.26
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 16MM 42-5224-004-16
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 16MM 42-5224-004-16
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 18MM 42-5224-004-18
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 18MM 42-5224-004-18
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 20MM 42-5224-004-20
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.48 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,391.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.57
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,587.88
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.30
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,709.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.30
|
| Rate for Payer: The Alliance Commercial |
$4,391.92
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 20MM 42-5224-004-20
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.08 |
| Max. Negotiated Rate |
$8,081.13 |
| Rate for Payer: Aetna Commercial |
$7,905.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.44
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$8,081.13
|
| Rate for Payer: Health EOS Commercial |
$7,817.62
|
| Rate for Payer: HFN Commercial |
$8,081.13
|
| Rate for Payer: Multiplan Commercial |
$7,027.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.13
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.08
|
| Rate for Payer: Quartz Commercial |
$5,270.30
|
| Rate for Payer: WEA Trust Commercial |
$4,831.11
|
| Rate for Payer: WPS Commercial |
$6,505.95
|
|
|
PERSONALITY AND IMPULSE CONTROL DIAGNOSES
|
Facility
|
OP
|
$49.99
|
|
|
Service Code
|
EAPG 00822
|
| Min. Negotiated Rate |
$48.07 |
| Max. Negotiated Rate |
$49.99 |
| Rate for Payer: Anthem Medicaid |
$48.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$48.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.07
|
| Rate for Payer: Dean Health Medicaid |
$48.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$48.07
|
| Rate for Payer: Managed Health Services Medicaid |
$49.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$48.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$48.07
|
| Rate for Payer: United Healthcare Medicaid |
$48.07
|
|
|
PERSONALITY DISORDERS
|
Facility
|
IP
|
$3,419.64
|
|
|
Service Code
|
APR-DRG 7521
|
| Min. Negotiated Rate |
$3,037.54 |
| Max. Negotiated Rate |
$3,419.64 |
| Rate for Payer: Anthem Medicaid |
$3,274.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,274.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,274.49
|
| Rate for Payer: Dean Health Medicaid |
$3,274.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,037.54
|
| Rate for Payer: Managed Health Services Medicaid |
$3,419.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,274.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,274.49
|
| Rate for Payer: United Healthcare Medicaid |
$3,274.49
|
|
|
PERSONALITY DISORDERS
|
Facility
|
IP
|
$9,995.87
|
|
|
Service Code
|
APR-DRG 7523
|
| Min. Negotiated Rate |
$8,878.96 |
| Max. Negotiated Rate |
$9,995.87 |
| Rate for Payer: Anthem Medicaid |
$9,571.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,571.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,571.60
|
| Rate for Payer: Dean Health Medicaid |
$9,571.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,878.96
|
| Rate for Payer: Managed Health Services Medicaid |
$9,995.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,571.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,571.60
|
| Rate for Payer: United Healthcare Medicaid |
$9,571.60
|
|
|
PERSONALITY DISORDERS
|
Facility
|
IP
|
$4,471.84
|
|
|
Service Code
|
APR-DRG 7522
|
| Min. Negotiated Rate |
$3,972.17 |
| Max. Negotiated Rate |
$4,471.84 |
| Rate for Payer: Anthem Medicaid |
$4,282.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,282.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,282.03
|
| Rate for Payer: Dean Health Medicaid |
$4,282.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,972.17
|
| Rate for Payer: Managed Health Services Medicaid |
$4,471.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,282.03
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,282.03
|
| Rate for Payer: United Healthcare Medicaid |
$4,282.03
|
|
|
PERSONALITY DISORDERS
|
Facility
|
IP
|
$23,762.12
|
|
|
Service Code
|
APR-DRG 7524
|
| Min. Negotiated Rate |
$21,107.00 |
| Max. Negotiated Rate |
$23,762.12 |
| Rate for Payer: Anthem Medicaid |
$22,753.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$22,753.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22,753.54
|
| Rate for Payer: Dean Health Medicaid |
$22,753.54
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21,107.00
|
| Rate for Payer: Managed Health Services Medicaid |
$23,762.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,753.54
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22,753.54
|
| Rate for Payer: United Healthcare Medicaid |
$22,753.54
|
|
