|
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: 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: 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
|
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 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 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 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 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
|
|
|
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 |
$4,138.54 |
| 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 13MM 42-5224-004-13
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962671
|
|
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 13MM 42-5224-004-13
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962671
|
|
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 14MM RT 42-5224-004-14
|
Facility
|
OP
|
$9,089.00
|
|
| Hospital Charge Code |
5286608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,544.92 |
| Max. Negotiated Rate |
$36,356.00 |
| Rate for Payer: Aetna Commercial |
$8,180.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,816.54
|
| Rate for Payer: Aetna Managed Medicare |
$2,544.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,907.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,544.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,362.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,817.17
|
| Rate for Payer: Cash Price |
$2,726.70
|
| Rate for Payer: Cigna Commercial |
$8,361.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,086.20
|
| Rate for Payer: Health EOS Commercial |
$8,089.21
|
| Rate for Payer: HFN Commercial |
$8,361.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,816.75
|
| Rate for Payer: Multiplan Commercial |
$7,271.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,453.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,361.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.61
|
| Rate for Payer: Quartz Commercial |
$5,907.85
|
| Rate for Payer: Quartz Medicare Advantage |
$5,453.40
|
| Rate for Payer: The Alliance Commercial |
$36,356.00
|
| Rate for Payer: WEA Trust Commercial |
$4,998.95
|
| Rate for Payer: WPS Commercial |
$6,732.22
|
|
|
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 |
$4,453.61 |
| Max. Negotiated Rate |
$8,361.88 |
| Rate for Payer: Aetna Commercial |
$8,180.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,816.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,817.17
|
| Rate for Payer: Cash Price |
$2,726.70
|
| Rate for Payer: Cigna Commercial |
$8,361.88
|
| Rate for Payer: Health EOS Commercial |
$8,089.21
|
| Rate for Payer: HFN Commercial |
$8,361.88
|
| Rate for Payer: Multiplan Commercial |
$7,271.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,453.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,361.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.61
|
| Rate for Payer: Quartz Commercial |
$5,453.40
|
| Rate for Payer: WEA Trust Commercial |
$4,998.95
|
| Rate for Payer: WPS Commercial |
$6,732.22
|
|
|
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 |
$4,138.54 |
| 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 16MM 42-5224-004-16
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962675
|
|
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 18MM 42-5224-004-18
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962677
|
|
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 18MM 42-5224-004-18
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962677
|
|
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 20MM 42-5224-004-20
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962678
|
|
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 20MM 42-5224-004-20
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962678
|
|
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
|
|
|
Pertussis toxin IgA
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgA
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$13.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.90
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.19
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.19
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.19
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.19
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$19.78
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$57.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13.19
|
| Rate for Payer: The Alliance Commercial |
$52.76
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare PPO |
$66.75
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: Wellcare Medicare |
$13.19
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgA
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.40
|
| Rate for Payer: Health EOS Commercial |
$80.99
|
| Rate for Payer: HFN Commercial |
$84.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.56
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.55
|
| Rate for Payer: Quartz Beloit One Network |
$39.16
|
| Rate for Payer: Quartz Commercial |
$50.73
|
| Rate for Payer: The Alliance Commercial |
$44.50
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgG
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgG
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$13.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.90
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.19
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.19
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.19
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.19
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$19.78
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$57.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13.19
|
| Rate for Payer: The Alliance Commercial |
$52.76
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare PPO |
$66.75
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: Wellcare Medicare |
$13.19
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgG
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.40
|
| Rate for Payer: Health EOS Commercial |
$80.99
|
| Rate for Payer: HFN Commercial |
$84.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.56
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.55
|
| Rate for Payer: Quartz Beloit One Network |
$39.16
|
| Rate for Payer: Quartz Commercial |
$50.73
|
| Rate for Payer: The Alliance Commercial |
$44.50
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pessary, non rubber, any type A4562
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$209.26 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.00
|
| Rate for Payer: Health EOS Commercial |
$95.55
|
| Rate for Payer: HFN Commercial |
$99.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$209.26
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$99.75
|
| Rate for Payer: Quartz Beloit One Network |
$46.20
|
| Rate for Payer: Quartz Commercial |
$59.85
|
| Rate for Payer: The Alliance Commercial |
$52.50
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
