|
Positive - Urine Pregnancy POC
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
3120176
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$157.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Aetna Managed Medicare |
$8.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.67
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.86
|
| Rate for Payer: Anthem Medicare Advantage |
$8.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.95
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$160.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.95
|
| Rate for Payer: Health EOS Commercial |
$155.50
|
| Rate for Payer: HFN Commercial |
$160.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.95
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: NAPHCARE Commercial |
$13.43
|
| Rate for Payer: Preferred Network Access Commercial |
$160.74
|
| Rate for Payer: Quartz Beloit One Network |
$85.61
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: Quartz Medicare Advantage |
$8.95
|
| Rate for Payer: The Alliance Commercial |
$35.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.95
|
| Rate for Payer: United Healthcare PPO |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: Wellcare Medicare |
$8.95
|
| Rate for Payer: WPS Commercial |
$129.41
|
|
|
Positive - Urine Pregnancy POC
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
3120176
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.61 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$157.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.60
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$160.74
|
| Rate for Payer: Health EOS Commercial |
$155.50
|
| Rate for Payer: HFN Commercial |
$160.74
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: Preferred Network Access Commercial |
$160.74
|
| Rate for Payer: Quartz Beloit One Network |
$85.61
|
| Rate for Payer: Quartz Commercial |
$104.83
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: WPS Commercial |
$129.41
|
|
|
POST CENTRAL MODULAR UNIVERS REVERS MODULAR GLENOID 20MM AR-9561-20P
|
Facility
|
OP
|
$7,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6065665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.73 |
| Max. Negotiated Rate |
$6,705.25 |
| Rate for Payer: Aetna Commercial |
$6,559.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,267.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,040.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,737.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,644.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,498.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,862.81
|
| Rate for Payer: Cash Price |
$2,102.40
|
| Rate for Payer: Cigna Commercial |
$6,705.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,078.66
|
| Rate for Payer: Health EOS Commercial |
$6,486.60
|
| Rate for Payer: HFN Commercial |
$6,705.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,466.24
|
| Rate for Payer: Multiplan Commercial |
$5,830.66
|
| Rate for Payer: NAPHCARE Commercial |
$4,372.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,705.25
|
| Rate for Payer: Quartz Beloit One Network |
$3,571.28
|
| Rate for Payer: Quartz Commercial |
$4,737.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4,372.99
|
| Rate for Payer: The Alliance Commercial |
$3,644.16
|
| Rate for Payer: WEA Trust Commercial |
$4,008.58
|
| Rate for Payer: WPS Commercial |
$5,398.26
|
|
|
POST CENTRAL MODULAR UNIVERS REVERS MODULAR GLENOID 20MM AR-9561-20P
|
Facility
|
IP
|
$7,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6065665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,571.28 |
| Max. Negotiated Rate |
$6,705.25 |
| Rate for Payer: Aetna Commercial |
$6,559.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,267.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,862.81
|
| Rate for Payer: Cash Price |
$2,102.40
|
| Rate for Payer: Cigna Commercial |
$6,705.25
|
| Rate for Payer: Health EOS Commercial |
$6,486.60
|
| Rate for Payer: HFN Commercial |
$6,705.25
|
| Rate for Payer: Multiplan Commercial |
$5,830.66
|
| Rate for Payer: Preferred Network Access Commercial |
$6,705.25
|
| Rate for Payer: Quartz Beloit One Network |
$3,571.28
|
| Rate for Payer: Quartz Commercial |
$4,372.99
|
| Rate for Payer: WEA Trust Commercial |
$4,008.58
|
| Rate for Payer: WPS Commercial |
$5,398.26
|
|
|
POST CENTRAL MODULAR UNIVERS REVERS MODULAR GLENOID 25MM AR-9561-25P
|
Facility
|
IP
|
$7,580.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563387
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,862.77 |
| Max. Negotiated Rate |
$7,252.54 |
| Rate for Payer: Aetna Commercial |
$7,094.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,779.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,178.10
|
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Cigna Commercial |
$7,252.54
|
| Rate for Payer: Health EOS Commercial |
$7,016.05
|
| Rate for Payer: HFN Commercial |
$7,252.54
|
| Rate for Payer: Multiplan Commercial |
$6,306.56
|
| Rate for Payer: Preferred Network Access Commercial |
$7,252.54
|
| Rate for Payer: Quartz Beloit One Network |
$3,862.77
|
| Rate for Payer: Quartz Commercial |
$4,729.92
|
| Rate for Payer: WEA Trust Commercial |
$4,335.76
|
| Rate for Payer: WPS Commercial |
$5,838.87
|
|
|
POST CENTRAL MODULAR UNIVERS REVERS MODULAR GLENOID 25MM AR-9561-25P
|
Facility
|
OP
|
$7,580.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563387
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,207.30 |
| Max. Negotiated Rate |
$7,252.54 |
| Rate for Payer: Aetna Commercial |
$7,094.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,779.55
|
| Rate for Payer: Aetna Managed Medicare |
$2,207.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,124.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,941.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,783.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,178.10
|
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Cigna Commercial |
$7,252.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,411.56
|
| Rate for Payer: Health EOS Commercial |
$7,016.05
|
| Rate for Payer: HFN Commercial |
$7,252.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,912.40
|
| Rate for Payer: Multiplan Commercial |
$6,306.56
|
| Rate for Payer: NAPHCARE Commercial |
$4,729.92
|
| Rate for Payer: Preferred Network Access Commercial |
$7,252.54
|
| Rate for Payer: Quartz Beloit One Network |
$3,862.77
|
| Rate for Payer: Quartz Commercial |
$5,124.08
|
| Rate for Payer: Quartz Medicare Advantage |
$4,729.92
|
| Rate for Payer: The Alliance Commercial |
$3,941.60
|
| Rate for Payer: WEA Trust Commercial |
$4,335.76
|
| Rate for Payer: WPS Commercial |
$5,838.87
|
|
|
Post ED Visit/ Called Back - ED Other Charges
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
3228171
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.74 |
| Max. Negotiated Rate |
$666.64 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Aetna Managed Medicare |
$88.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$666.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$477.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$453.44
|
| Rate for Payer: Anthem Medicare Advantage |
$88.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$88.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$88.74
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$88.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$88.74
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$330.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$88.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$88.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$88.74
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: NAPHCARE Commercial |
$133.11
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$154.13
|
| Rate for Payer: Quartz Medicare Advantage |
$88.74
|
| Rate for Payer: The Alliance Commercial |
$354.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$88.74
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: Wellcare Medicare |
$88.74
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
Post ED Visit/ Called Back - ED Other Charges
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
3228171
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$116.19 |
| Max. Negotiated Rate |
$218.15 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.67
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$142.27
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
Post ED Vist/Called Back - FCT03
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
CPT FCT03
|
| Hospital Charge Code |
5516690
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$154.92 |
| Max. Negotiated Rate |
$290.87 |
| Rate for Payer: Aetna Commercial |
$284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.56
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$290.87
|
| Rate for Payer: Health EOS Commercial |
$281.38
|
| Rate for Payer: HFN Commercial |
$290.87
|
| Rate for Payer: Multiplan Commercial |
$252.93
|
| Rate for Payer: Preferred Network Access Commercial |
$290.87
|
| Rate for Payer: Quartz Beloit One Network |
$154.92
|
| Rate for Payer: Quartz Commercial |
$189.70
|
| Rate for Payer: WEA Trust Commercial |
$173.89
|
| Rate for Payer: WPS Commercial |
$234.17
|
|
|
Post ED Vist/Called Back - FCT03
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT FCT03
|
| Hospital Charge Code |
5516690
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.52 |
| Max. Negotiated Rate |
$313.04 |
| Rate for Payer: Aetna Commercial |
$284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.90
|
| Rate for Payer: Aetna Managed Medicare |
$88.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$205.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$158.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$151.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.56
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$290.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$176.93
|
| Rate for Payer: Health EOS Commercial |
$281.38
|
| Rate for Payer: HFN Commercial |
$290.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.12
|
| Rate for Payer: Multiplan Commercial |
$252.93
|
| Rate for Payer: NAPHCARE Commercial |
$189.70
|
| Rate for Payer: Preferred Network Access Commercial |
$290.87
|
| Rate for Payer: Quartz Beloit One Network |
$154.92
|
| Rate for Payer: Quartz Commercial |
$205.50
|
| Rate for Payer: Quartz Medicare Advantage |
$189.70
|
| Rate for Payer: The Alliance Commercial |
$158.08
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$173.89
|
| Rate for Payer: WPS Commercial |
$234.17
|
|
|
Post-Emergency Delivery Care - Individual Charges
|
Facility
|
IP
|
$3,189.00
|
|
| Hospital Charge Code |
3003927
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,625.11 |
| Max. Negotiated Rate |
$3,051.24 |
| Rate for Payer: Aetna Commercial |
$2,984.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,852.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,757.78
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cigna Commercial |
$3,051.24
|
| Rate for Payer: Health EOS Commercial |
$2,951.74
|
| Rate for Payer: HFN Commercial |
$3,051.24
|
| Rate for Payer: Multiplan Commercial |
$2,653.25
|
| Rate for Payer: Preferred Network Access Commercial |
$3,051.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,625.11
|
| Rate for Payer: Quartz Commercial |
$1,989.94
|
| Rate for Payer: WEA Trust Commercial |
$1,824.11
|
| Rate for Payer: WPS Commercial |
$2,456.49
|
|
|
Post-Emergency Delivery Care - Individual Charges
|
Facility
|
OP
|
$3,189.00
|
|
| Hospital Charge Code |
3003927
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$928.64 |
| Max. Negotiated Rate |
$3,051.24 |
| Rate for Payer: Aetna Commercial |
$2,984.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,852.24
|
| Rate for Payer: Aetna Managed Medicare |
$928.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,155.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,658.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,591.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,757.78
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cigna Commercial |
$3,051.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,856.00
|
| Rate for Payer: Health EOS Commercial |
$2,951.74
|
| Rate for Payer: HFN Commercial |
$3,051.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,487.42
|
| Rate for Payer: Multiplan Commercial |
$2,653.25
|
| Rate for Payer: NAPHCARE Commercial |
$1,989.94
|
| Rate for Payer: Preferred Network Access Commercial |
$3,051.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,625.11
|
| Rate for Payer: Quartz Commercial |
$2,155.76
|
| Rate for Payer: Quartz Medicare Advantage |
$1,989.94
|
| Rate for Payer: The Alliance Commercial |
$1,658.28
|
| Rate for Payer: United Healthcare PPO |
$2,487.42
|
| Rate for Payer: WEA Trust Commercial |
$1,824.11
|
| Rate for Payer: WPS Commercial |
$2,456.49
|
|
|
Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
|
Facility
|
OP
|
$21,058.09
|
|
|
Service Code
|
CPT 57250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$21,058.09 |
| Rate for Payer: Aetna Managed Medicare |
$5,264.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$5,264.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,264.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,264.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,264.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,673.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,264.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,584.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,264.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,264.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,264.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,264.52
|
| Rate for Payer: NAPHCARE Commercial |
$7,896.78
|
| Rate for Payer: Quartz Medicare Advantage |
$5,264.52
|
| Rate for Payer: The Alliance Commercial |
$21,058.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,264.52
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: Wellcare Medicare |
$5,264.52
|
|
|
POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
|
Facility
|
OP
|
$8,339.00
|
|
| Hospital Charge Code |
2960309
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,428.32 |
| Max. Negotiated Rate |
$7,978.76 |
| Rate for Payer: Aetna Commercial |
$7,805.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,458.40
|
| Rate for Payer: Aetna Managed Medicare |
$2,428.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,637.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,336.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,162.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,596.46
|
| Rate for Payer: Cash Price |
$2,501.70
|
| Rate for Payer: Cigna Commercial |
$7,978.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,853.30
|
| Rate for Payer: Health EOS Commercial |
$7,718.58
|
| Rate for Payer: HFN Commercial |
$7,978.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,504.42
|
| Rate for Payer: Multiplan Commercial |
$6,938.05
|
| Rate for Payer: NAPHCARE Commercial |
$5,203.54
|
| Rate for Payer: Preferred Network Access Commercial |
$7,978.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,249.55
|
| Rate for Payer: Quartz Commercial |
$5,637.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5,203.54
|
| Rate for Payer: The Alliance Commercial |
$4,336.28
|
| Rate for Payer: WEA Trust Commercial |
$4,769.91
|
| Rate for Payer: WPS Commercial |
$6,423.53
|
|
|
POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
|
Facility
|
IP
|
$8,339.00
|
|
| Hospital Charge Code |
2960309
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,249.55 |
| Max. Negotiated Rate |
$7,978.76 |
| Rate for Payer: Aetna Commercial |
$7,805.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,458.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,596.46
|
| Rate for Payer: Cash Price |
$2,501.70
|
| Rate for Payer: Cigna Commercial |
$7,978.76
|
| Rate for Payer: Health EOS Commercial |
$7,718.58
|
| Rate for Payer: HFN Commercial |
$7,978.76
|
| Rate for Payer: Multiplan Commercial |
$6,938.05
|
| Rate for Payer: Preferred Network Access Commercial |
$7,978.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,249.55
|
| Rate for Payer: Quartz Commercial |
$5,203.54
|
| Rate for Payer: WEA Trust Commercial |
$4,769.91
|
| Rate for Payer: WPS Commercial |
$6,423.53
|
|
|
Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (list separately in addition to code for primary procedure)
|
Facility
|
OP
|
$12,349.86
|
|
|
Service Code
|
CPT 22840
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,395.24 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: The Alliance Commercial |
$2,395.24
|
|
|
Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (list separately in addition to code for primary procedure)
|
Facility
|
OP
|
$12,349.86
|
|
|
Service Code
|
CPT 22842
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,419.50 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: The Alliance Commercial |
$2,419.50
|
|
|
POST.FEM.PRESSURIZER 65 DEG 0606-514-000
|
Facility
|
IP
|
$314.00
|
|
| Hospital Charge Code |
2963241
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$160.01 |
| Max. Negotiated Rate |
$300.44 |
| Rate for Payer: Aetna Commercial |
$293.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.08
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$300.44
|
| Rate for Payer: Health EOS Commercial |
$290.64
|
| Rate for Payer: HFN Commercial |
$300.44
|
| Rate for Payer: Multiplan Commercial |
$261.25
|
| Rate for Payer: Preferred Network Access Commercial |
$300.44
|
| Rate for Payer: Quartz Beloit One Network |
$160.01
|
| Rate for Payer: Quartz Commercial |
$195.94
|
| Rate for Payer: WEA Trust Commercial |
$179.61
|
| Rate for Payer: WPS Commercial |
$241.87
|
|
|
POST.FEM.PRESSURIZER 65 DEG 0606-514-000
|
Facility
|
OP
|
$314.00
|
|
| Hospital Charge Code |
2963241
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$91.44 |
| Max. Negotiated Rate |
$300.44 |
| Rate for Payer: Aetna Commercial |
$293.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.84
|
| Rate for Payer: Aetna Managed Medicare |
$91.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$212.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$163.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$156.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.08
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$300.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.75
|
| Rate for Payer: Health EOS Commercial |
$290.64
|
| Rate for Payer: HFN Commercial |
$300.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$244.92
|
| Rate for Payer: Multiplan Commercial |
$261.25
|
| Rate for Payer: NAPHCARE Commercial |
$195.94
|
| Rate for Payer: Preferred Network Access Commercial |
$300.44
|
| Rate for Payer: Quartz Beloit One Network |
$160.01
|
| Rate for Payer: Quartz Commercial |
$212.26
|
| Rate for Payer: Quartz Medicare Advantage |
$195.94
|
| Rate for Payer: The Alliance Commercial |
$163.28
|
| Rate for Payer: WEA Trust Commercial |
$179.61
|
| Rate for Payer: WPS Commercial |
$241.87
|
|
|
POST HOFFMANN 3 LARGE 30 DEG 4922-2-140
|
Facility
|
IP
|
$1,479.00
|
|
| Hospital Charge Code |
5685710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$753.70 |
| Max. Negotiated Rate |
$1,415.11 |
| Rate for Payer: Aetna Commercial |
$1,384.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,322.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$815.22
|
| Rate for Payer: Cash Price |
$443.70
|
| Rate for Payer: Cigna Commercial |
$1,415.11
|
| Rate for Payer: Health EOS Commercial |
$1,368.96
|
| Rate for Payer: HFN Commercial |
$1,415.11
|
| Rate for Payer: Multiplan Commercial |
$1,230.53
|
| Rate for Payer: Preferred Network Access Commercial |
$1,415.11
|
| Rate for Payer: Quartz Beloit One Network |
$753.70
|
| Rate for Payer: Quartz Commercial |
$922.90
|
| Rate for Payer: WEA Trust Commercial |
$845.99
|
| Rate for Payer: WPS Commercial |
$1,139.27
|
|
|
POST HOFFMANN 3 LARGE 30 DEG 4922-2-140
|
Facility
|
OP
|
$1,479.00
|
|
| Hospital Charge Code |
5685710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$430.68 |
| Max. Negotiated Rate |
$1,415.11 |
| Rate for Payer: Aetna Commercial |
$1,384.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,322.82
|
| Rate for Payer: Aetna Managed Medicare |
$430.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$999.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$769.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$738.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$815.22
|
| Rate for Payer: Cash Price |
$443.70
|
| Rate for Payer: Cigna Commercial |
$1,415.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$860.78
|
| Rate for Payer: Health EOS Commercial |
$1,368.96
|
| Rate for Payer: HFN Commercial |
$1,415.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,153.62
|
| Rate for Payer: Multiplan Commercial |
$1,230.53
|
| Rate for Payer: NAPHCARE Commercial |
$922.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,415.11
|
| Rate for Payer: Quartz Beloit One Network |
$753.70
|
| Rate for Payer: Quartz Commercial |
$999.80
|
| Rate for Payer: Quartz Medicare Advantage |
$922.90
|
| Rate for Payer: The Alliance Commercial |
$769.08
|
| Rate for Payer: WEA Trust Commercial |
$845.99
|
| Rate for Payer: WPS Commercial |
$1,139.27
|
|
|
POST MODULAR 20MM AR-9582-20
|
Facility
|
IP
|
$7,415.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,778.68 |
| Max. Negotiated Rate |
$7,094.67 |
| Rate for Payer: Aetna Commercial |
$6,940.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,631.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,087.15
|
| Rate for Payer: Cash Price |
$2,224.50
|
| Rate for Payer: Cigna Commercial |
$7,094.67
|
| Rate for Payer: Health EOS Commercial |
$6,863.32
|
| Rate for Payer: HFN Commercial |
$7,094.67
|
| Rate for Payer: Multiplan Commercial |
$6,169.28
|
| Rate for Payer: Preferred Network Access Commercial |
$7,094.67
|
| Rate for Payer: Quartz Beloit One Network |
$3,778.68
|
| Rate for Payer: Quartz Commercial |
$4,626.96
|
| Rate for Payer: WEA Trust Commercial |
$4,241.38
|
| Rate for Payer: WPS Commercial |
$5,711.77
|
|
|
POST MODULAR 20MM AR-9582-20
|
Facility
|
OP
|
$7,415.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$7,094.67 |
| Rate for Payer: Aetna Commercial |
$6,940.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,631.98
|
| Rate for Payer: Aetna Managed Medicare |
$2,159.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,012.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,855.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,701.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,087.15
|
| Rate for Payer: Cash Price |
$2,224.50
|
| Rate for Payer: Cigna Commercial |
$7,094.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,315.53
|
| Rate for Payer: Health EOS Commercial |
$6,863.32
|
| Rate for Payer: HFN Commercial |
$7,094.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,783.70
|
| Rate for Payer: Multiplan Commercial |
$6,169.28
|
| Rate for Payer: NAPHCARE Commercial |
$4,626.96
|
| Rate for Payer: Preferred Network Access Commercial |
$7,094.67
|
| Rate for Payer: Quartz Beloit One Network |
$3,778.68
|
| Rate for Payer: Quartz Commercial |
$5,012.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,626.96
|
| Rate for Payer: The Alliance Commercial |
$3,855.80
|
| Rate for Payer: WEA Trust Commercial |
$4,241.38
|
| Rate for Payer: WPS Commercial |
$5,711.77
|
|
|
POST MODULAR 25MM AR-9582-25
|
Facility
|
IP
|
$7,415.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659647
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,778.68 |
| Max. Negotiated Rate |
$7,094.67 |
| Rate for Payer: Aetna Commercial |
$6,940.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,631.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,087.15
|
| Rate for Payer: Cash Price |
$2,224.50
|
| Rate for Payer: Cigna Commercial |
$7,094.67
|
| Rate for Payer: Health EOS Commercial |
$6,863.32
|
| Rate for Payer: HFN Commercial |
$7,094.67
|
| Rate for Payer: Multiplan Commercial |
$6,169.28
|
| Rate for Payer: Preferred Network Access Commercial |
$7,094.67
|
| Rate for Payer: Quartz Beloit One Network |
$3,778.68
|
| Rate for Payer: Quartz Commercial |
$4,626.96
|
| Rate for Payer: WEA Trust Commercial |
$4,241.38
|
| Rate for Payer: WPS Commercial |
$5,711.77
|
|
|
POST MODULAR 25MM AR-9582-25
|
Facility
|
OP
|
$7,415.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659647
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$7,094.67 |
| Rate for Payer: Aetna Commercial |
$6,940.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,631.98
|
| Rate for Payer: Aetna Managed Medicare |
$2,159.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,012.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,855.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,701.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,087.15
|
| Rate for Payer: Cash Price |
$2,224.50
|
| Rate for Payer: Cigna Commercial |
$7,094.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,315.53
|
| Rate for Payer: Health EOS Commercial |
$6,863.32
|
| Rate for Payer: HFN Commercial |
$7,094.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,783.70
|
| Rate for Payer: Multiplan Commercial |
$6,169.28
|
| Rate for Payer: NAPHCARE Commercial |
$4,626.96
|
| Rate for Payer: Preferred Network Access Commercial |
$7,094.67
|
| Rate for Payer: Quartz Beloit One Network |
$3,778.68
|
| Rate for Payer: Quartz Commercial |
$5,012.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,626.96
|
| Rate for Payer: The Alliance Commercial |
$3,855.80
|
| Rate for Payer: WEA Trust Commercial |
$4,241.38
|
| Rate for Payer: WPS Commercial |
$5,711.77
|
|
