|
REVEAL KIT XT 5929
|
Facility
|
OP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103301
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,199.16 |
| Max. Negotiated Rate |
$59,988.00 |
| Rate for Payer: Aetna Commercial |
$13,497.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,897.42
|
| Rate for Payer: Aetna Managed Medicare |
$4,199.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,748.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,498.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,198.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,948.41
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$13,797.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,392.32
|
| Rate for Payer: Health EOS Commercial |
$13,347.33
|
| Rate for Payer: HFN Commercial |
$13,797.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,247.75
|
| Rate for Payer: Multiplan Commercial |
$11,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,998.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,797.24
|
| Rate for Payer: Quartz Beloit One Network |
$7,348.53
|
| Rate for Payer: Quartz Commercial |
$9,748.05
|
| Rate for Payer: Quartz Medicare Advantage |
$8,998.20
|
| Rate for Payer: The Alliance Commercial |
$59,988.00
|
| Rate for Payer: WEA Trust Commercial |
$8,248.35
|
| Rate for Payer: WPS Commercial |
$11,108.28
|
|
|
REVEAL KIT XT 9539
|
Facility
|
IP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103300
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,348.53 |
| Max. Negotiated Rate |
$13,797.24 |
| Rate for Payer: Aetna Commercial |
$13,497.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,897.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,948.41
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$13,797.24
|
| Rate for Payer: Health EOS Commercial |
$13,347.33
|
| Rate for Payer: HFN Commercial |
$13,797.24
|
| Rate for Payer: Multiplan Commercial |
$11,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,998.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,797.24
|
| Rate for Payer: Quartz Beloit One Network |
$7,348.53
|
| Rate for Payer: Quartz Commercial |
$8,998.20
|
| Rate for Payer: WEA Trust Commercial |
$8,248.35
|
| Rate for Payer: WPS Commercial |
$11,108.28
|
|
|
REVEAL KIT XT 9539
|
Facility
|
OP
|
$14,997.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
3103300
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,199.16 |
| Max. Negotiated Rate |
$59,988.00 |
| Rate for Payer: Aetna Commercial |
$13,497.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,897.42
|
| Rate for Payer: Aetna Managed Medicare |
$4,199.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,748.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,498.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,198.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,948.41
|
| Rate for Payer: Cash Price |
$4,499.10
|
| Rate for Payer: Cigna Commercial |
$13,797.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,392.32
|
| Rate for Payer: Health EOS Commercial |
$13,347.33
|
| Rate for Payer: HFN Commercial |
$13,797.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,247.75
|
| Rate for Payer: Multiplan Commercial |
$11,997.60
|
| Rate for Payer: NAPHCARE Commercial |
$8,998.20
|
| Rate for Payer: Preferred Network Access Commercial |
$13,797.24
|
| Rate for Payer: Quartz Beloit One Network |
$7,348.53
|
| Rate for Payer: Quartz Commercial |
$9,748.05
|
| Rate for Payer: Quartz Medicare Advantage |
$8,998.20
|
| Rate for Payer: The Alliance Commercial |
$59,988.00
|
| Rate for Payer: WEA Trust Commercial |
$8,248.35
|
| Rate for Payer: WPS Commercial |
$11,108.28
|
|
|
Reveal Linq Loop Recorder
|
Facility
|
OP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
4125535
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,873.68 |
| Max. Negotiated Rate |
$69,624.00 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Aetna Managed Medicare |
$4,873.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,313.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,740.40
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,054.50
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$11,313.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,443.60
|
| Rate for Payer: The Alliance Commercial |
$69,624.00
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
Reveal Linq Loop Recorder
|
Facility
|
IP
|
$17,406.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
4125535
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$8,528.94 |
| Max. Negotiated Rate |
$16,013.52 |
| Rate for Payer: Aetna Commercial |
$15,665.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,969.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,225.18
|
| Rate for Payer: Cash Price |
$5,221.80
|
| Rate for Payer: Cigna Commercial |
$16,013.52
|
| Rate for Payer: Health EOS Commercial |
$15,491.34
|
| Rate for Payer: HFN Commercial |
$16,013.52
|
| Rate for Payer: Multiplan Commercial |
$13,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,443.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16,013.52
|
| Rate for Payer: Quartz Beloit One Network |
$8,528.94
|
| Rate for Payer: Quartz Commercial |
$10,443.60
|
| Rate for Payer: WEA Trust Commercial |
$9,573.30
|
| Rate for Payer: WPS Commercial |
$12,892.62
|
|
|
REVISE EXTERNAL EAR 69300
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
CPT 69300
|
| Hospital Charge Code |
3015265
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$396.00 |
| Max. Negotiated Rate |
$2,331.37 |
| Rate for Payer: Aetna Commercial |
$855.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$774.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$855.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,331.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$540.00
|
| Rate for Payer: Health EOS Commercial |
$819.00
|
| Rate for Payer: HFN Commercial |
$855.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,538.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,538.44
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Preferred Network Access Commercial |
$855.00
|
| Rate for Payer: Quartz Beloit One Network |
$396.00
|
| Rate for Payer: Quartz Commercial |
$513.00
|
| Rate for Payer: The Alliance Commercial |
$450.00
|
| Rate for Payer: United Healthcare Medicaid |
$2,331.37
|
| Rate for Payer: WEA Trust Commercial |
$495.00
|
| Rate for Payer: WPS Commercial |
$666.63
|
|
|
REVISION KIT BONE DOWEL 10MM ABS-2850-10
|
Facility
|
OP
|
$5,164.00
|
|
| Hospital Charge Code |
5547230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,445.92 |
| Max. Negotiated Rate |
$20,656.00 |
| Rate for Payer: Aetna Commercial |
$4,647.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,441.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,445.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,356.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,582.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,478.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,736.92
|
| Rate for Payer: Cash Price |
$1,549.20
|
| Rate for Payer: Cigna Commercial |
$4,750.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,889.77
|
| Rate for Payer: Health EOS Commercial |
$4,595.96
|
| Rate for Payer: HFN Commercial |
$4,750.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,873.00
|
| Rate for Payer: Multiplan Commercial |
$4,131.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,098.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,750.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,530.36
|
| Rate for Payer: Quartz Commercial |
$3,356.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,098.40
|
| Rate for Payer: The Alliance Commercial |
$20,656.00
|
| Rate for Payer: WEA Trust Commercial |
$2,840.20
|
| Rate for Payer: WPS Commercial |
$3,824.97
|
|
|
REVISION KIT BONE DOWEL 10MM ABS-2850-10
|
Facility
|
IP
|
$5,164.00
|
|
| Hospital Charge Code |
5547230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,530.36 |
| Max. Negotiated Rate |
$4,750.88 |
| Rate for Payer: Aetna Commercial |
$4,647.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,441.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,736.92
|
| Rate for Payer: Cash Price |
$1,549.20
|
| Rate for Payer: Cigna Commercial |
$4,750.88
|
| Rate for Payer: Health EOS Commercial |
$4,595.96
|
| Rate for Payer: HFN Commercial |
$4,750.88
|
| Rate for Payer: Multiplan Commercial |
$4,131.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,098.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,750.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,530.36
|
| Rate for Payer: Quartz Commercial |
$3,098.40
|
| Rate for Payer: WEA Trust Commercial |
$2,840.20
|
| Rate for Payer: WPS Commercial |
$3,824.97
|
|
|
REVISION KIT BONE DOWEL 12MM ABS-2850-12
|
Facility
|
IP
|
$5,164.00
|
|
| Hospital Charge Code |
6172044
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,530.36 |
| Max. Negotiated Rate |
$4,750.88 |
| Rate for Payer: Aetna Commercial |
$4,647.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,441.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,736.92
|
| Rate for Payer: Cash Price |
$1,549.20
|
| Rate for Payer: Cigna Commercial |
$4,750.88
|
| Rate for Payer: Health EOS Commercial |
$4,595.96
|
| Rate for Payer: HFN Commercial |
$4,750.88
|
| Rate for Payer: Multiplan Commercial |
$4,131.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,098.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,750.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,530.36
|
| Rate for Payer: Quartz Commercial |
$3,098.40
|
| Rate for Payer: WEA Trust Commercial |
$2,840.20
|
| Rate for Payer: WPS Commercial |
$3,824.97
|
|
|
REVISION KIT BONE DOWEL 12MM ABS-2850-12
|
Facility
|
OP
|
$5,164.00
|
|
| Hospital Charge Code |
6172044
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,445.92 |
| Max. Negotiated Rate |
$20,656.00 |
| Rate for Payer: Aetna Commercial |
$4,647.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,441.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,445.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,356.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,582.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,478.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,736.92
|
| Rate for Payer: Cash Price |
$1,549.20
|
| Rate for Payer: Cigna Commercial |
$4,750.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,889.77
|
| Rate for Payer: Health EOS Commercial |
$4,595.96
|
| Rate for Payer: HFN Commercial |
$4,750.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,873.00
|
| Rate for Payer: Multiplan Commercial |
$4,131.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,098.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,750.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,530.36
|
| Rate for Payer: Quartz Commercial |
$3,356.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,098.40
|
| Rate for Payer: The Alliance Commercial |
$20,656.00
|
| Rate for Payer: WEA Trust Commercial |
$2,840.20
|
| Rate for Payer: WPS Commercial |
$3,824.97
|
|
|
REVISION KIT BONE DOWEL 14MM ABS-2850-14
|
Facility
|
OP
|
$5,274.00
|
|
| Hospital Charge Code |
6172045
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,476.72 |
| Max. Negotiated Rate |
$21,096.00 |
| Rate for Payer: Aetna Commercial |
$4,746.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,535.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,476.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,428.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,637.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,531.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,795.22
|
| Rate for Payer: Cash Price |
$1,582.20
|
| Rate for Payer: Cigna Commercial |
$4,852.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,951.33
|
| Rate for Payer: Health EOS Commercial |
$4,693.86
|
| Rate for Payer: HFN Commercial |
$4,852.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,955.50
|
| Rate for Payer: Multiplan Commercial |
$4,219.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,852.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,584.26
|
| Rate for Payer: Quartz Commercial |
$3,428.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,164.40
|
| Rate for Payer: The Alliance Commercial |
$21,096.00
|
| Rate for Payer: WEA Trust Commercial |
$2,900.70
|
| Rate for Payer: WPS Commercial |
$3,906.45
|
|
|
REVISION KIT BONE DOWEL 14MM ABS-2850-14
|
Facility
|
IP
|
$5,274.00
|
|
| Hospital Charge Code |
6172045
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,584.26 |
| Max. Negotiated Rate |
$4,852.08 |
| Rate for Payer: Aetna Commercial |
$4,746.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,535.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,795.22
|
| Rate for Payer: Cash Price |
$1,582.20
|
| Rate for Payer: Cigna Commercial |
$4,852.08
|
| Rate for Payer: Health EOS Commercial |
$4,693.86
|
| Rate for Payer: HFN Commercial |
$4,852.08
|
| Rate for Payer: Multiplan Commercial |
$4,219.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,852.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,584.26
|
| Rate for Payer: Quartz Commercial |
$3,164.40
|
| Rate for Payer: WEA Trust Commercial |
$2,900.70
|
| Rate for Payer: WPS Commercial |
$3,906.45
|
|
|
REVISION KIT INTERSTIM II 3560031
|
Facility
|
OP
|
$3,736.00
|
|
| Hospital Charge Code |
6201072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,046.08 |
| Max. Negotiated Rate |
$14,944.00 |
| Rate for Payer: Aetna Commercial |
$3,362.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,212.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,046.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,428.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,868.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,793.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,980.08
|
| Rate for Payer: Cash Price |
$1,120.80
|
| Rate for Payer: Cigna Commercial |
$3,437.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,090.67
|
| Rate for Payer: Health EOS Commercial |
$3,325.04
|
| Rate for Payer: HFN Commercial |
$3,437.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,802.00
|
| Rate for Payer: Multiplan Commercial |
$2,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,241.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,437.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,830.64
|
| Rate for Payer: Quartz Commercial |
$2,428.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,241.60
|
| Rate for Payer: The Alliance Commercial |
$14,944.00
|
| Rate for Payer: WEA Trust Commercial |
$2,054.80
|
| Rate for Payer: WPS Commercial |
$2,767.26
|
|
|
REVISION KIT INTERSTIM II 3560031
|
Facility
|
IP
|
$3,736.00
|
|
| Hospital Charge Code |
6201072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,830.64 |
| Max. Negotiated Rate |
$3,437.12 |
| Rate for Payer: Aetna Commercial |
$3,362.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,212.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,980.08
|
| Rate for Payer: Cash Price |
$1,120.80
|
| Rate for Payer: Cigna Commercial |
$3,437.12
|
| Rate for Payer: Health EOS Commercial |
$3,325.04
|
| Rate for Payer: HFN Commercial |
$3,437.12
|
| Rate for Payer: Multiplan Commercial |
$2,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,241.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,437.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,830.64
|
| Rate for Payer: Quartz Commercial |
$2,241.60
|
| Rate for Payer: WEA Trust Commercial |
$2,054.80
|
| Rate for Payer: WPS Commercial |
$2,767.26
|
|
|
REVISION OF BIG TOE 28310
|
Professional
|
Both
|
$1,512.00
|
|
|
Service Code
|
CPT 28310
|
| Hospital Charge Code |
3014242
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$180.80 |
| Max. Negotiated Rate |
$1,436.40 |
| Rate for Payer: Aetna Commercial |
$1,436.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,300.32
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cigna Commercial |
$1,436.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$180.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$907.20
|
| Rate for Payer: Health EOS Commercial |
$1,375.92
|
| Rate for Payer: HFN Commercial |
$1,436.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,215.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,215.73
|
| Rate for Payer: Multiplan Commercial |
$1,209.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,436.40
|
| Rate for Payer: Quartz Beloit One Network |
$665.28
|
| Rate for Payer: Quartz Commercial |
$861.84
|
| Rate for Payer: The Alliance Commercial |
$756.00
|
| Rate for Payer: United Healthcare Medicaid |
$180.80
|
| Rate for Payer: WEA Trust Commercial |
$831.60
|
| Rate for Payer: WPS Commercial |
$1,119.94
|
|
|
Revision Of Cornea
|
Professional
|
Both
|
$1,018.00
|
|
|
Service Code
|
CPT 65600
|
| Hospital Charge Code |
1190832
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$447.92 |
| Max. Negotiated Rate |
$1,142.41 |
| Rate for Payer: Aetna Commercial |
$967.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$875.48
|
| Rate for Payer: Cash Price |
$305.40
|
| Rate for Payer: Cash Price |
$305.40
|
| Rate for Payer: Cigna Commercial |
$967.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$452.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$610.80
|
| Rate for Payer: Health EOS Commercial |
$926.38
|
| Rate for Payer: HFN Commercial |
$967.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,142.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,142.41
|
| Rate for Payer: Multiplan Commercial |
$814.40
|
| Rate for Payer: Preferred Network Access Commercial |
$967.10
|
| Rate for Payer: Quartz Beloit One Network |
$447.92
|
| Rate for Payer: Quartz Commercial |
$580.26
|
| Rate for Payer: The Alliance Commercial |
$509.00
|
| Rate for Payer: United Healthcare Medicaid |
$452.00
|
| Rate for Payer: WEA Trust Commercial |
$559.90
|
| Rate for Payer: WPS Commercial |
$754.03
|
|
|
REVISION OF EYELID 67966
|
Professional
|
Both
|
$5,120.00
|
|
|
Service Code
|
CPT 67966
|
| Hospital Charge Code |
3015252
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$606.27 |
| Max. Negotiated Rate |
$4,864.00 |
| Rate for Payer: Aetna Commercial |
$4,864.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,403.20
|
| Rate for Payer: Cash Price |
$1,536.00
|
| Rate for Payer: Cash Price |
$1,536.00
|
| Rate for Payer: Cigna Commercial |
$4,864.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$606.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,072.00
|
| Rate for Payer: Health EOS Commercial |
$4,659.20
|
| Rate for Payer: HFN Commercial |
$4,864.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,197.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,197.04
|
| Rate for Payer: Multiplan Commercial |
$4,096.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,864.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,252.80
|
| Rate for Payer: Quartz Commercial |
$2,918.40
|
| Rate for Payer: The Alliance Commercial |
$2,560.00
|
| Rate for Payer: United Healthcare Medicaid |
$606.27
|
| Rate for Payer: WEA Trust Commercial |
$2,816.00
|
| Rate for Payer: WPS Commercial |
$3,792.38
|
|
|
REVISION OF FOOT FASCIA 28250
|
Professional
|
Both
|
$2,163.00
|
|
|
Service Code
|
CPT 28250
|
| Hospital Charge Code |
3014225
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$376.66 |
| Max. Negotiated Rate |
$2,054.85 |
| Rate for Payer: Aetna Commercial |
$2,054.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,860.18
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cigna Commercial |
$2,054.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$376.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,297.80
|
| Rate for Payer: Health EOS Commercial |
$1,968.33
|
| Rate for Payer: HFN Commercial |
$2,054.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,351.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,351.21
|
| Rate for Payer: Multiplan Commercial |
$1,730.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,054.85
|
| Rate for Payer: Quartz Beloit One Network |
$951.72
|
| Rate for Payer: Quartz Commercial |
$1,232.91
|
| Rate for Payer: The Alliance Commercial |
$1,081.50
|
| Rate for Payer: United Healthcare Medicaid |
$376.66
|
| Rate for Payer: WEA Trust Commercial |
$1,189.65
|
| Rate for Payer: WPS Commercial |
$1,602.13
|
|
|
REVISION OF FOOT TENDON 28238
|
Professional
|
Both
|
$4,118.00
|
|
|
Service Code
|
CPT 28238
|
| Hospital Charge Code |
3014223
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$452.00 |
| Max. Negotiated Rate |
$3,912.10 |
| Rate for Payer: Aetna Commercial |
$3,912.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,541.48
|
| Rate for Payer: Cash Price |
$1,235.40
|
| Rate for Payer: Cash Price |
$1,235.40
|
| Rate for Payer: Cigna Commercial |
$3,912.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$452.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,470.80
|
| Rate for Payer: Health EOS Commercial |
$3,747.38
|
| Rate for Payer: HFN Commercial |
$3,912.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,629.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,629.87
|
| Rate for Payer: Multiplan Commercial |
$3,294.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,912.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,811.92
|
| Rate for Payer: Quartz Commercial |
$2,347.26
|
| Rate for Payer: The Alliance Commercial |
$2,059.00
|
| Rate for Payer: United Healthcare Medicaid |
$452.00
|
| Rate for Payer: WEA Trust Commercial |
$2,264.90
|
| Rate for Payer: WPS Commercial |
$3,050.20
|
|
|
REVISION OF HIP OR KNEE REPLACEMENT WITH CC
|
Facility
|
IP
|
$93,007.00
|
|
|
Service Code
|
MSDRG 467
|
| Min. Negotiated Rate |
$33,455.78 |
| Max. Negotiated Rate |
$93,007.00 |
| Rate for Payer: Aetna Managed Medicare |
$33,455.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73,220.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56,122.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53,320.22
|
| Rate for Payer: Anthem Medicare Advantage |
$33,455.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33,455.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33,455.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$33,455.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59,190.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$33,455.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67,982.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33,455.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33,455.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$33,455.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$33,455.78
|
| Rate for Payer: NAPHCARE Commercial |
$50,183.67
|
| Rate for Payer: Quartz Medicare Advantage |
$33,455.78
|
| Rate for Payer: The Alliance Commercial |
$93,007.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33,455.78
|
| Rate for Payer: United Healthcare PPO |
$52,925.52
|
| Rate for Payer: Wellcare Medicare |
$33,455.78
|
|
|
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC
|
Facility
|
IP
|
$138,211.00
|
|
|
Service Code
|
MSDRG 466
|
| Min. Negotiated Rate |
$49,716.25 |
| Max. Negotiated Rate |
$138,211.00 |
| Rate for Payer: Aetna Managed Medicare |
$49,716.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$108,886.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83,460.39
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79,292.82
|
| Rate for Payer: Anthem Medicare Advantage |
$49,716.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49,716.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49,716.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49,716.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88,022.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49,716.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101,138.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49,716.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49,716.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49,716.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49,716.25
|
| Rate for Payer: NAPHCARE Commercial |
$74,574.38
|
| Rate for Payer: Quartz Medicare Advantage |
$49,716.25
|
| Rate for Payer: The Alliance Commercial |
$138,211.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49,716.25
|
| Rate for Payer: United Healthcare PPO |
$78,737.77
|
| Rate for Payer: Wellcare Medicare |
$49,716.25
|
|
|
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$71,294.00
|
|
|
Service Code
|
MSDRG 468
|
| Min. Negotiated Rate |
$25,645.44 |
| Max. Negotiated Rate |
$71,294.00 |
| Rate for Payer: Aetna Managed Medicare |
$25,645.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56,016.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42,936.27
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40,792.26
|
| Rate for Payer: Anthem Medicare Advantage |
$25,645.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25,645.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25,645.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25,645.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45,283.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25,645.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52,057.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25,645.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25,645.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25,645.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25,645.44
|
| Rate for Payer: NAPHCARE Commercial |
$38,468.16
|
| Rate for Payer: Quartz Medicare Advantage |
$25,645.44
|
| Rate for Payer: The Alliance Commercial |
$71,294.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25,645.44
|
| Rate for Payer: United Healthcare PPO |
$40,527.20
|
| Rate for Payer: Wellcare Medicare |
$25,645.44
|
|
|
REVISION OF LOWER LEG TENDON 27685
|
Professional
|
Both
|
$2,531.00
|
|
|
Service Code
|
CPT 27685
|
| Hospital Charge Code |
3014131
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$404.31 |
| Max. Negotiated Rate |
$2,404.45 |
| Rate for Payer: Aetna Commercial |
$2,404.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,176.66
|
| Rate for Payer: Cash Price |
$759.30
|
| Rate for Payer: Cash Price |
$759.30
|
| Rate for Payer: Cigna Commercial |
$2,404.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$404.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,518.60
|
| Rate for Payer: Health EOS Commercial |
$2,303.21
|
| Rate for Payer: HFN Commercial |
$2,404.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,558.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,558.81
|
| Rate for Payer: Multiplan Commercial |
$2,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,404.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,113.64
|
| Rate for Payer: Quartz Commercial |
$1,442.67
|
| Rate for Payer: The Alliance Commercial |
$1,265.50
|
| Rate for Payer: United Healthcare Medicaid |
$404.31
|
| Rate for Payer: WEA Trust Commercial |
$1,392.05
|
| Rate for Payer: WPS Commercial |
$1,874.71
|
|
|
Revision of Nose 30120
|
Professional
|
Both
|
$1,135.00
|
|
|
Service Code
|
CPT 30120
|
| Hospital Charge Code |
3147588
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$499.40 |
| Max. Negotiated Rate |
$1,420.68 |
| Rate for Payer: Aetna Commercial |
$1,078.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$976.10
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cash Price |
$340.50
|
| Rate for Payer: Cigna Commercial |
$1,078.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$527.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$681.00
|
| Rate for Payer: Health EOS Commercial |
$1,032.85
|
| Rate for Payer: HFN Commercial |
$1,078.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,420.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,420.68
|
| Rate for Payer: Multiplan Commercial |
$908.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,078.25
|
| Rate for Payer: Quartz Beloit One Network |
$499.40
|
| Rate for Payer: Quartz Commercial |
$646.95
|
| Rate for Payer: The Alliance Commercial |
$567.50
|
| Rate for Payer: United Healthcare Medicaid |
$527.35
|
| Rate for Payer: WEA Trust Commercial |
$624.25
|
| Rate for Payer: WPS Commercial |
$840.69
|
|
|
REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT
|
Facility
|
OP
|
$17,483.00
|
|
|
Service Code
|
CPT 27486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,452.00 |
| Max. Negotiated Rate |
$17,483.00 |
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,483.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,081.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,278.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: United Healthcare PPO |
$8,452.00
|
|
