|
SKN SPLT A-GRFT FAC/NCK/HF/G 15120
|
Professional
|
$3,886.00
|
|
|
Service Code
|
CPT 15120
|
| Hospital Charge Code |
3013636
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$643.95 |
| Max. Negotiated Rate |
$3,691.70 |
| Rate for Payer: Aetna Commercial |
$3,691.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,341.96
|
| Rate for Payer: Aetna Managed Medicare |
$643.95
|
| Rate for Payer: Anthem Medicare Advantage |
$643.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$643.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$643.95
|
| Rate for Payer: Cash Price |
$1,165.80
|
| Rate for Payer: Cash Price |
$1,165.80
|
| Rate for Payer: Cigna Commercial |
$3,691.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,943.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$643.95
|
| Rate for Payer: Health EOS Commercial |
$3,536.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,285.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,285.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$643.95
|
| Rate for Payer: Multiplan Commercial |
$3,108.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,691.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,709.84
|
| Rate for Payer: Quartz Commercial |
$2,215.02
|
| Rate for Payer: Quartz Medicare Advantage |
$643.95
|
| Rate for Payer: The Alliance Commercial |
$2,736.79
|
| Rate for Payer: United Healthcare Medicaid |
$784.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$643.95
|
| Rate for Payer: WEA Trust Commercial |
$2,137.30
|
| Rate for Payer: WPS Commercial |
$2,897.78
|
|
|
SLEEP APNEA CPAP
|
Facility
OP
|
$7,668.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
3059529
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$1,033.42 |
| Max. Negotiated Rate |
$7,054.56 |
| Rate for Payer: Aetna Commercial |
$6,901.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,594.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,033.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,033.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,064.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,033.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,033.42
|
| Rate for Payer: Cash Price |
$2,300.40
|
| Rate for Payer: Cash Price |
$2,300.40
|
| Rate for Payer: Cash Price |
$2,300.40
|
| Rate for Payer: Cigna Commercial |
$7,054.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,033.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,291.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,033.42
|
| Rate for Payer: Health EOS Commercial |
$6,824.52
|
| Rate for Payer: HFN Commercial |
$7,054.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,844.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,033.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,033.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,033.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,033.42
|
| Rate for Payer: Multiplan Commercial |
$6,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,550.13
|
| Rate for Payer: Preferred Network Access Commercial |
$7,054.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,757.32
|
| Rate for Payer: Quartz Commercial |
$4,984.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,033.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,033.42
|
| Rate for Payer: United Healthcare PPO |
$5,751.00
|
| Rate for Payer: WEA Trust Commercial |
$4,217.40
|
| Rate for Payer: Wellcare Medicare |
$1,033.42
|
| Rate for Payer: WPS Commercial |
$5,679.69
|
|
|
SLEEP APNEA CPAP
|
Facility
IP
|
$7,668.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
3059529
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$3,757.32 |
| Max. Negotiated Rate |
$7,054.56 |
| Rate for Payer: Aetna Commercial |
$6,901.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,064.04
|
| Rate for Payer: Cash Price |
$2,300.40
|
| Rate for Payer: Cigna Commercial |
$7,054.56
|
| Rate for Payer: Health EOS Commercial |
$6,824.52
|
| Rate for Payer: HFN Commercial |
$7,054.56
|
| Rate for Payer: Multiplan Commercial |
$6,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,600.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,054.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,757.32
|
| Rate for Payer: Quartz Commercial |
$4,600.80
|
| Rate for Payer: WEA Trust Commercial |
$4,217.40
|
| Rate for Payer: WPS Commercial |
$5,679.69
|
|
|
SLEEP APNEA PROCEDURE
|
Facility
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960378
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
SLEEP APNEA PROCEDURE
|
Facility
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960378
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATT 9580626
|
Professional
|
$1,023.00
|
|
|
Service Code
|
CPT 95806 26
|
| Hospital Charge Code |
6172223
|
|
Hospital Revenue Code
|
511
|
| Min. Negotiated Rate |
$42.24 |
| Max. Negotiated Rate |
$971.85 |
| Rate for Payer: Aetna Commercial |
$971.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$879.78
|
| Rate for Payer: Aetna Managed Medicare |
$42.24
|
| Rate for Payer: Anthem Medicare Advantage |
$42.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$42.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$42.24
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna Commercial |
$971.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$511.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.24
|
| Rate for Payer: Health EOS Commercial |
$930.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$154.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$42.24
|
| Rate for Payer: Multiplan Commercial |
$818.40
|
| Rate for Payer: Preferred Network Access Commercial |
$971.85
|
| Rate for Payer: Quartz Beloit One Network |
$450.12
|
| Rate for Payer: Quartz Commercial |
$583.11
|
| Rate for Payer: Quartz Medicare Advantage |
$42.24
|
| Rate for Payer: The Alliance Commercial |
$105.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.24
|
| Rate for Payer: WEA Trust Commercial |
$562.65
|
| Rate for Payer: WPS Commercial |
$168.96
|
|
|
SLEEVE COMPRESSION LARGE
|
Facility
IP
|
$465.00
|
|
| Hospital Charge Code |
2963056
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$227.85 |
| Max. Negotiated Rate |
$427.80 |
| Rate for Payer: Aetna Commercial |
$418.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.45
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$427.80
|
| Rate for Payer: Health EOS Commercial |
$413.85
|
| Rate for Payer: HFN Commercial |
$427.80
|
| Rate for Payer: Multiplan Commercial |
$372.00
|
| Rate for Payer: NAPHCARE Commercial |
$279.00
|
| Rate for Payer: Preferred Network Access Commercial |
$427.80
|
| Rate for Payer: Quartz Beloit One Network |
$227.85
|
| Rate for Payer: Quartz Commercial |
$279.00
|
| Rate for Payer: WEA Trust Commercial |
$255.75
|
| Rate for Payer: WPS Commercial |
$344.43
|
|
|
SLEEVE COMPRESSION LARGE
|
Facility
OP
|
$465.00
|
|
| Hospital Charge Code |
2963056
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$1,860.00 |
| Rate for Payer: Aetna Commercial |
$418.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.90
|
| Rate for Payer: Aetna Managed Medicare |
$130.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$302.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$232.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$223.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.45
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$427.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$260.21
|
| Rate for Payer: Health EOS Commercial |
$413.85
|
| Rate for Payer: HFN Commercial |
$427.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$348.75
|
| Rate for Payer: Multiplan Commercial |
$372.00
|
| Rate for Payer: NAPHCARE Commercial |
$279.00
|
| Rate for Payer: Preferred Network Access Commercial |
$427.80
|
| Rate for Payer: Quartz Beloit One Network |
$227.85
|
| Rate for Payer: Quartz Commercial |
$302.25
|
| Rate for Payer: Quartz Medicare Advantage |
$279.00
|
| Rate for Payer: The Alliance Commercial |
$1,860.00
|
| Rate for Payer: WEA Trust Commercial |
$255.75
|
| Rate for Payer: WPS Commercial |
$344.43
|
|
|
SLEEVE COMPRESSION MEDIUM
|
Facility
IP
|
$285.00
|
|
| Hospital Charge Code |
2963266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
SLEEVE COMPRESSION MEDIUM
|
Facility
OP
|
$285.00
|
|
| Hospital Charge Code |
2963266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$1,140.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
SLEEVE COMPRESSION-XL
|
Facility
OP
|
$915.00
|
|
| Hospital Charge Code |
2975049
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$3,660.00 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Aetna Managed Medicare |
$256.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$594.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$457.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.03
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.25
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$594.75
|
| Rate for Payer: Quartz Medicare Advantage |
$549.00
|
| Rate for Payer: The Alliance Commercial |
$3,660.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE COMPRESSION-XL
|
Facility
IP
|
$915.00
|
|
| Hospital Charge Code |
2975049
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$448.35 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$549.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE RESORBABLE FOR 5.0 ANGU
|
Facility
IP
|
$2,608.00
|
|
| Hospital Charge Code |
2966584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,277.92 |
| Max. Negotiated Rate |
$2,399.36 |
| Rate for Payer: Aetna Commercial |
$2,347.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,382.24
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,399.36
|
| Rate for Payer: Health EOS Commercial |
$2,321.12
|
| Rate for Payer: HFN Commercial |
$2,399.36
|
| Rate for Payer: Multiplan Commercial |
$2,086.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,564.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,399.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,277.92
|
| Rate for Payer: Quartz Commercial |
$1,564.80
|
| Rate for Payer: WEA Trust Commercial |
$1,434.40
|
| Rate for Payer: WPS Commercial |
$1,931.75
|
|
|
SLEEVE RESORBABLE FOR 5.0 ANGU
|
Facility
OP
|
$2,608.00
|
|
| Hospital Charge Code |
2966584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$730.24 |
| Max. Negotiated Rate |
$10,432.00 |
| Rate for Payer: Aetna Commercial |
$2,347.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,242.88
|
| Rate for Payer: Aetna Managed Medicare |
$730.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,695.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,304.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,251.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,382.24
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,399.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,459.44
|
| Rate for Payer: Health EOS Commercial |
$2,321.12
|
| Rate for Payer: HFN Commercial |
$2,399.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,956.00
|
| Rate for Payer: Multiplan Commercial |
$2,086.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,564.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,399.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,277.92
|
| Rate for Payer: Quartz Commercial |
$1,695.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,564.80
|
| Rate for Payer: The Alliance Commercial |
$10,432.00
|
| Rate for Payer: WEA Trust Commercial |
$1,434.40
|
| Rate for Payer: WPS Commercial |
$1,931.75
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 29MM 1294-54-000
|
Facility
OP
|
$14,721.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,121.88 |
| Max. Negotiated Rate |
$13,543.32 |
| Rate for Payer: Aetna Commercial |
$13,248.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,660.06
|
| Rate for Payer: Aetna Managed Medicare |
$4,121.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,568.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,360.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,066.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,802.13
|
| Rate for Payer: Cash Price |
$4,416.30
|
| Rate for Payer: Cigna Commercial |
$13,543.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,237.87
|
| Rate for Payer: Health EOS Commercial |
$13,101.69
|
| Rate for Payer: HFN Commercial |
$13,543.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,040.75
|
| Rate for Payer: Multiplan Commercial |
$11,776.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,832.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,543.32
|
| Rate for Payer: Quartz Beloit One Network |
$7,213.29
|
| Rate for Payer: Quartz Commercial |
$9,568.65
|
| Rate for Payer: Quartz Medicare Advantage |
$8,832.60
|
| Rate for Payer: WEA Trust Commercial |
$8,096.55
|
| Rate for Payer: WPS Commercial |
$10,903.84
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 29MM 1294-54-000
|
Facility
IP
|
$14,721.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,213.29 |
| Max. Negotiated Rate |
$13,543.32 |
| Rate for Payer: Aetna Commercial |
$13,248.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,802.13
|
| Rate for Payer: Cash Price |
$4,416.30
|
| Rate for Payer: Cigna Commercial |
$13,543.32
|
| Rate for Payer: Health EOS Commercial |
$13,101.69
|
| Rate for Payer: HFN Commercial |
$13,543.32
|
| Rate for Payer: Multiplan Commercial |
$11,776.80
|
| Rate for Payer: NAPHCARE Commercial |
$8,832.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,543.32
|
| Rate for Payer: Quartz Beloit One Network |
$7,213.29
|
| Rate for Payer: Quartz Commercial |
$8,832.60
|
| Rate for Payer: WEA Trust Commercial |
$8,096.55
|
| Rate for Payer: WPS Commercial |
$10,903.84
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 45MM 1294-54-110
|
Facility
OP
|
$20,246.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,668.88 |
| Max. Negotiated Rate |
$18,626.32 |
| Rate for Payer: Aetna Commercial |
$18,221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,411.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,668.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,159.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,718.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,730.38
|
| Rate for Payer: Cash Price |
$6,073.80
|
| Rate for Payer: Cigna Commercial |
$18,626.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,329.66
|
| Rate for Payer: Health EOS Commercial |
$18,018.94
|
| Rate for Payer: HFN Commercial |
$18,626.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,184.50
|
| Rate for Payer: Multiplan Commercial |
$16,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$18,626.32
|
| Rate for Payer: Quartz Beloit One Network |
$9,920.54
|
| Rate for Payer: Quartz Commercial |
$13,159.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12,147.60
|
| Rate for Payer: WEA Trust Commercial |
$11,135.30
|
| Rate for Payer: WPS Commercial |
$14,996.21
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 45MM 1294-54-110
|
Facility
IP
|
$20,246.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,920.54 |
| Max. Negotiated Rate |
$18,626.32 |
| Rate for Payer: Aetna Commercial |
$18,221.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,730.38
|
| Rate for Payer: Cash Price |
$6,073.80
|
| Rate for Payer: Cigna Commercial |
$18,626.32
|
| Rate for Payer: Health EOS Commercial |
$18,018.94
|
| Rate for Payer: HFN Commercial |
$18,626.32
|
| Rate for Payer: Multiplan Commercial |
$16,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$18,626.32
|
| Rate for Payer: Quartz Beloit One Network |
$9,920.54
|
| Rate for Payer: Quartz Commercial |
$12,147.60
|
| Rate for Payer: WEA Trust Commercial |
$11,135.30
|
| Rate for Payer: WPS Commercial |
$14,996.21
|
|
|
SLEEVE SPEEDGUIDE 70-3932
|
Facility
IP
|
$4,241.00
|
|
| Hospital Charge Code |
3791364
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,078.09 |
| Max. Negotiated Rate |
$3,901.72 |
| Rate for Payer: Aetna Commercial |
$3,816.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,247.73
|
| Rate for Payer: Cash Price |
$1,272.30
|
| Rate for Payer: Cigna Commercial |
$3,901.72
|
| Rate for Payer: Health EOS Commercial |
$3,774.49
|
| Rate for Payer: HFN Commercial |
$3,901.72
|
| Rate for Payer: Multiplan Commercial |
$3,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,544.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,901.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,078.09
|
| Rate for Payer: Quartz Commercial |
$2,544.60
|
| Rate for Payer: WEA Trust Commercial |
$2,332.55
|
| Rate for Payer: WPS Commercial |
$3,141.31
|
|
|
SLEEVE SPEEDGUIDE 70-3932
|
Facility
OP
|
$4,241.00
|
|
| Hospital Charge Code |
3791364
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,187.48 |
| Max. Negotiated Rate |
$16,964.00 |
| Rate for Payer: Aetna Commercial |
$3,816.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,647.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,187.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,756.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,120.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,035.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,247.73
|
| Rate for Payer: Cash Price |
$1,272.30
|
| Rate for Payer: Cigna Commercial |
$3,901.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,373.26
|
| Rate for Payer: Health EOS Commercial |
$3,774.49
|
| Rate for Payer: HFN Commercial |
$3,901.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,180.75
|
| Rate for Payer: Multiplan Commercial |
$3,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,544.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,901.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,078.09
|
| Rate for Payer: Quartz Commercial |
$2,756.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,544.60
|
| Rate for Payer: The Alliance Commercial |
$16,964.00
|
| Rate for Payer: WEA Trust Commercial |
$2,332.55
|
| Rate for Payer: WPS Commercial |
$3,141.31
|
|
|
SLEEVES SURGICAL 89791
|
Facility
IP
|
$54.00
|
|
| Hospital Charge Code |
2963249
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
SLEEVES SURGICAL 89791
|
Facility
OP
|
$54.00
|
|
| Hospital Charge Code |
2963249
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
SLEEVE STERILE
|
Facility
IP
|
$367.00
|
|
| Hospital Charge Code |
2972925
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$179.83 |
| Max. Negotiated Rate |
$337.64 |
| Rate for Payer: Aetna Commercial |
$330.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.51
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$337.64
|
| Rate for Payer: Health EOS Commercial |
$326.63
|
| Rate for Payer: HFN Commercial |
$337.64
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: NAPHCARE Commercial |
$220.20
|
| Rate for Payer: Preferred Network Access Commercial |
$337.64
|
| Rate for Payer: Quartz Beloit One Network |
$179.83
|
| Rate for Payer: Quartz Commercial |
$220.20
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
SLEEVE STERILE
|
Facility
OP
|
$367.00
|
|
| Hospital Charge Code |
2972925
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$102.76 |
| Max. Negotiated Rate |
$1,468.00 |
| Rate for Payer: Aetna Commercial |
$330.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.62
|
| Rate for Payer: Aetna Managed Medicare |
$102.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$238.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$183.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.51
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$337.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.37
|
| Rate for Payer: Health EOS Commercial |
$326.63
|
| Rate for Payer: HFN Commercial |
$337.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.25
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: NAPHCARE Commercial |
$220.20
|
| Rate for Payer: Preferred Network Access Commercial |
$337.64
|
| Rate for Payer: Quartz Beloit One Network |
$179.83
|
| Rate for Payer: Quartz Commercial |
$238.55
|
| Rate for Payer: Quartz Medicare Advantage |
$220.20
|
| Rate for Payer: The Alliance Commercial |
$1,468.00
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +12MM 6942-6-080
|
Facility
OP
|
$916.00
|
|
| Hospital Charge Code |
4518659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.48 |
| Max. Negotiated Rate |
$3,664.00 |
| Rate for Payer: Aetna Commercial |
$824.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$787.76
|
| Rate for Payer: Aetna Managed Medicare |
$256.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$595.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$458.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$485.48
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$842.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.59
|
| Rate for Payer: Health EOS Commercial |
$815.24
|
| Rate for Payer: HFN Commercial |
$842.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$687.00
|
| Rate for Payer: Multiplan Commercial |
$732.80
|
| Rate for Payer: NAPHCARE Commercial |
$549.60
|
| Rate for Payer: Preferred Network Access Commercial |
$842.72
|
| Rate for Payer: Quartz Beloit One Network |
$448.84
|
| Rate for Payer: Quartz Commercial |
$595.40
|
| Rate for Payer: Quartz Medicare Advantage |
$549.60
|
| Rate for Payer: The Alliance Commercial |
$3,664.00
|
| Rate for Payer: WEA Trust Commercial |
$503.80
|
| Rate for Payer: WPS Commercial |
$678.48
|
|
