|
EVERCROSS BALLOON 12MM X 20MM X80
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972520
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
EVERCROSS BALLOON 12MM X 20MM X80
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972520
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
EVERCROSS BALLOON 12MM X 40MM
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972521
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
EVERCROSS BALLOON 12MM X 40MM
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972521
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Everolimus Level
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
3475536
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.47 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna Commercial |
$228.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$228.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.60
|
| Rate for Payer: Health EOS Commercial |
$219.31
|
| Rate for Payer: HFN Commercial |
$228.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.47
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.95
|
| Rate for Payer: Quartz Beloit One Network |
$106.04
|
| Rate for Payer: Quartz Commercial |
$137.37
|
| Rate for Payer: The Alliance Commercial |
$120.50
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Everolimus Level
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
3475536
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Aetna Managed Medicare |
$13.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.79
|
| Rate for Payer: Anthem Medicaid |
$14.19
|
| Rate for Payer: Anthem Medicare Advantage |
$13.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.86
|
| Rate for Payer: Dean Health Medicaid |
$14.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.73
|
| Rate for Payer: Managed Health Services Medicaid |
$14.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.73
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$20.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.19
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$156.65
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$54.92
|
| Rate for Payer: United Healthcare Medicaid |
$14.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.73
|
| Rate for Payer: United Healthcare PPO |
$180.75
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: Wellcare Medicare |
$13.73
|
| Rate for Payer: WMAP Medicaid |
$14.19
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Everolimus Level
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
3475536
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$144.60
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
EVOKED AUDITORY TEST 9258726
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
CPT 92587 26
|
| Hospital Charge Code |
3015342
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.00
|
| Rate for Payer: Health EOS Commercial |
$91.00
|
| Rate for Payer: HFN Commercial |
$95.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.19
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: Preferred Network Access Commercial |
$95.00
|
| Rate for Payer: Quartz Beloit One Network |
$44.00
|
| Rate for Payer: Quartz Commercial |
$57.00
|
| Rate for Payer: The Alliance Commercial |
$50.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
Evoked Otoacoustic Emissions; Comprehensive/Diagnostic Eval
|
Professional
|
Both
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
1188813
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.96 |
| Max. Negotiated Rate |
$505.40 |
| Rate for Payer: Aetna Commercial |
$505.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$457.52
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$505.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$77.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$319.20
|
| Rate for Payer: Health EOS Commercial |
$484.12
|
| Rate for Payer: HFN Commercial |
$505.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$117.20
|
| Rate for Payer: Multiplan Commercial |
$425.60
|
| Rate for Payer: Preferred Network Access Commercial |
$505.40
|
| Rate for Payer: Quartz Beloit One Network |
$234.08
|
| Rate for Payer: Quartz Commercial |
$303.24
|
| Rate for Payer: The Alliance Commercial |
$266.00
|
| Rate for Payer: United Healthcare Medicaid |
$77.96
|
| Rate for Payer: WEA Trust Commercial |
$292.60
|
| Rate for Payer: WPS Commercial |
$394.05
|
|
|
Evoked Otoacoustic Emissions; Comprehensive/Diagnostic Eval
|
Facility
|
IP
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
1188813
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$260.68 |
| Max. Negotiated Rate |
$489.44 |
| Rate for Payer: Aetna Commercial |
$478.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$457.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.96
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$489.44
|
| Rate for Payer: Health EOS Commercial |
$473.48
|
| Rate for Payer: HFN Commercial |
$489.44
|
| Rate for Payer: Multiplan Commercial |
$425.60
|
| Rate for Payer: NAPHCARE Commercial |
$319.20
|
| Rate for Payer: Preferred Network Access Commercial |
$489.44
|
| Rate for Payer: Quartz Beloit One Network |
$260.68
|
| Rate for Payer: Quartz Commercial |
$319.20
|
| Rate for Payer: WEA Trust Commercial |
$292.60
|
| Rate for Payer: WPS Commercial |
$394.05
|
|
|
Evoked Otoacoustic Emissions; Comprehensive/Diagnostic Eval
|
Facility
|
OP
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
1188813
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$255.36 |
| Max. Negotiated Rate |
$1,240.96 |
| Rate for Payer: Aetna Commercial |
$478.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$457.52
|
| Rate for Payer: Aetna Managed Medicare |
$310.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$345.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$266.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.36
|
| Rate for Payer: Anthem Medicare Advantage |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$310.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$489.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$310.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$310.24
|
| Rate for Payer: Health EOS Commercial |
$473.48
|
| Rate for Payer: HFN Commercial |
$489.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,154.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$310.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$310.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$310.24
|
| Rate for Payer: Multiplan Commercial |
$425.60
|
| Rate for Payer: NAPHCARE Commercial |
$465.36
|
| Rate for Payer: Preferred Network Access Commercial |
$489.44
|
| Rate for Payer: Quartz Beloit One Network |
$260.68
|
| Rate for Payer: Quartz Commercial |
$345.80
|
| Rate for Payer: Quartz Medicare Advantage |
$310.24
|
| Rate for Payer: The Alliance Commercial |
$1,240.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$310.24
|
| Rate for Payer: WEA Trust Commercial |
$292.60
|
| Rate for Payer: Wellcare Medicare |
$310.24
|
| Rate for Payer: WPS Commercial |
$394.05
|
|
|
EXCALIBUR 4.0MM X 13CM ARTHROSCOPY ARTHREX AR-8400EX
|
Facility
|
OP
|
$959.00
|
|
| Hospital Charge Code |
5074914
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.52 |
| Max. Negotiated Rate |
$3,836.00 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Aetna Managed Medicare |
$268.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$623.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$479.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$460.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$536.66
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$719.25
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$623.35
|
| Rate for Payer: Quartz Medicare Advantage |
$575.40
|
| Rate for Payer: The Alliance Commercial |
$3,836.00
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
EXCALIBUR 4.0MM X 13CM ARTHROSCOPY ARTHREX AR-8400EX
|
Facility
|
IP
|
$959.00
|
|
| Hospital Charge Code |
5074914
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$469.91 |
| Max. Negotiated Rate |
$882.28 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$575.40
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
EXCALIBUR 4.0MM X 13CM CURVED ARTHROSCOPY ARTHREX AR-8400CEX
|
Facility
|
OP
|
$959.00
|
|
| Hospital Charge Code |
5074915
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.52 |
| Max. Negotiated Rate |
$3,836.00 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Aetna Managed Medicare |
$268.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$623.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$479.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$460.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$536.66
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$719.25
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$623.35
|
| Rate for Payer: Quartz Medicare Advantage |
$575.40
|
| Rate for Payer: The Alliance Commercial |
$3,836.00
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
EXCALIBUR 4.0MM X 13CM CURVED ARTHROSCOPY ARTHREX AR-8400CEX
|
Facility
|
IP
|
$959.00
|
|
| Hospital Charge Code |
5074915
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$469.91 |
| Max. Negotiated Rate |
$882.28 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$575.40
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
EXCALIBUR 4.2MM X 19CM ARTHROSCOPY ARTHREX AR-6420EX
|
Facility
|
OP
|
$1,229.00
|
|
| Hospital Charge Code |
5074891
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$344.12 |
| Max. Negotiated Rate |
$4,916.00 |
| Rate for Payer: Aetna Commercial |
$1,106.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,056.94
|
| Rate for Payer: Aetna Managed Medicare |
$344.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$798.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$614.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$589.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$651.37
|
| Rate for Payer: Cash Price |
$368.70
|
| Rate for Payer: Cigna Commercial |
$1,130.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$687.75
|
| Rate for Payer: Health EOS Commercial |
$1,093.81
|
| Rate for Payer: HFN Commercial |
$1,130.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$921.75
|
| Rate for Payer: Multiplan Commercial |
$983.20
|
| Rate for Payer: NAPHCARE Commercial |
$737.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,130.68
|
| Rate for Payer: Quartz Beloit One Network |
$602.21
|
| Rate for Payer: Quartz Commercial |
$798.85
|
| Rate for Payer: Quartz Medicare Advantage |
$737.40
|
| Rate for Payer: The Alliance Commercial |
$4,916.00
|
| Rate for Payer: WEA Trust Commercial |
$675.95
|
| Rate for Payer: WPS Commercial |
$910.32
|
|
|
EXCALIBUR 4.2MM X 19CM ARTHROSCOPY ARTHREX AR-6420EX
|
Facility
|
IP
|
$1,229.00
|
|
| Hospital Charge Code |
5074891
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$602.21 |
| Max. Negotiated Rate |
$1,130.68 |
| Rate for Payer: Aetna Commercial |
$1,106.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,056.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$651.37
|
| Rate for Payer: Cash Price |
$368.70
|
| Rate for Payer: Cigna Commercial |
$1,130.68
|
| Rate for Payer: Health EOS Commercial |
$1,093.81
|
| Rate for Payer: HFN Commercial |
$1,130.68
|
| Rate for Payer: Multiplan Commercial |
$983.20
|
| Rate for Payer: NAPHCARE Commercial |
$737.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,130.68
|
| Rate for Payer: Quartz Beloit One Network |
$602.21
|
| Rate for Payer: Quartz Commercial |
$737.40
|
| Rate for Payer: WEA Trust Commercial |
$675.95
|
| Rate for Payer: WPS Commercial |
$910.32
|
|
|
EXCALIBUR 5.0MM ARTHROSCOPY ARTHREX AR-8500EX
|
Facility
|
IP
|
$959.00
|
|
| Hospital Charge Code |
5206673
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$469.91 |
| Max. Negotiated Rate |
$882.28 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$575.40
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
EXCALIBUR 5.0MM ARTHROSCOPY ARTHREX AR-8500EX
|
Facility
|
OP
|
$959.00
|
|
| Hospital Charge Code |
5206673
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.52 |
| Max. Negotiated Rate |
$3,836.00 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Aetna Managed Medicare |
$268.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$623.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$479.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$460.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$536.66
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$719.25
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$623.35
|
| Rate for Payer: Quartz Medicare Advantage |
$575.40
|
| Rate for Payer: The Alliance Commercial |
$3,836.00
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
EXCHANGE NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION
|
Facility
|
OP
|
$8,052.80
|
|
|
Service Code
|
CPT 50435
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,013.20 |
| Max. Negotiated Rate |
$8,052.80 |
| Rate for Payer: Aetna Managed Medicare |
$2,013.20
|
| 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 |
$2,013.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,013.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,013.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,013.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,013.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,489.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,013.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,013.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,013.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,013.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,019.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,013.20
|
| Rate for Payer: The Alliance Commercial |
$8,052.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,013.20
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$2,013.20
|
|
|
Exc hip pelvis les sc over 3 cm 27043
|
Professional
|
Both
|
$3,040.00
|
|
|
Service Code
|
CPT 27043
|
| Hospital Charge Code |
3014009
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$377.55 |
| Max. Negotiated Rate |
$2,888.00 |
| Rate for Payer: Aetna Commercial |
$2,888.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,614.40
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Cigna Commercial |
$2,888.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$377.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,824.00
|
| Rate for Payer: Health EOS Commercial |
$2,766.40
|
| Rate for Payer: HFN Commercial |
$2,888.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,528.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,528.91
|
| Rate for Payer: Multiplan Commercial |
$2,432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,888.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,337.60
|
| Rate for Payer: Quartz Commercial |
$1,732.80
|
| Rate for Payer: The Alliance Commercial |
$1,520.00
|
| Rate for Payer: United Healthcare Medicaid |
$377.55
|
| Rate for Payer: WEA Trust Commercial |
$1,672.00
|
| Rate for Payer: WPS Commercial |
$2,251.73
|
|
|
EXCHNG ABSC/CST DRG CATH RAD GID SPX 49423
|
Professional
|
Both
|
$465.00
|
|
|
Service Code
|
CPT 49423
|
| Hospital Charge Code |
6180166
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$204.60 |
| Max. Negotiated Rate |
$500.61 |
| Rate for Payer: Aetna Commercial |
$441.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.90
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$441.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$500.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$279.00
|
| Rate for Payer: Health EOS Commercial |
$423.15
|
| Rate for Payer: HFN Commercial |
$441.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$237.96
|
| Rate for Payer: Multiplan Commercial |
$372.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.75
|
| Rate for Payer: Quartz Beloit One Network |
$204.60
|
| Rate for Payer: Quartz Commercial |
$265.05
|
| Rate for Payer: The Alliance Commercial |
$232.50
|
| Rate for Payer: United Healthcare Medicaid |
$500.61
|
| Rate for Payer: WEA Trust Commercial |
$255.75
|
| Rate for Payer: WPS Commercial |
$344.43
|
|
|
EXCISE FOOT TENDON SHEATH 28086
|
Professional
|
Both
|
$2,365.00
|
|
|
Service Code
|
CPT 28086
|
| Hospital Charge Code |
3014195
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$421.85 |
| Max. Negotiated Rate |
$2,246.75 |
| Rate for Payer: Aetna Commercial |
$2,246.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,033.90
|
| Rate for Payer: Cash Price |
$709.50
|
| Rate for Payer: Cash Price |
$709.50
|
| Rate for Payer: Cigna Commercial |
$2,246.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$421.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,419.00
|
| Rate for Payer: Health EOS Commercial |
$2,152.15
|
| Rate for Payer: HFN Commercial |
$2,246.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,195.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,195.58
|
| Rate for Payer: Multiplan Commercial |
$1,892.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,246.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,040.60
|
| Rate for Payer: Quartz Commercial |
$1,348.05
|
| Rate for Payer: The Alliance Commercial |
$1,182.50
|
| Rate for Payer: United Healthcare Medicaid |
$421.85
|
| Rate for Payer: WEA Trust Commercial |
$1,300.75
|
| Rate for Payer: WPS Commercial |
$1,751.76
|
|
|
EXCISE LIP OR CHEEK FOLD 40819
|
Professional
|
Both
|
$562.00
|
|
|
Service Code
|
CPT 40819
|
| Hospital Charge Code |
3014609
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.77 |
| Max. Negotiated Rate |
$686.94 |
| Rate for Payer: Aetna Commercial |
$533.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$483.32
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$533.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$337.20
|
| Rate for Payer: Health EOS Commercial |
$511.42
|
| Rate for Payer: HFN Commercial |
$533.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$686.94
|
| Rate for Payer: Multiplan Commercial |
$449.60
|
| Rate for Payer: Preferred Network Access Commercial |
$533.90
|
| Rate for Payer: Quartz Beloit One Network |
$247.28
|
| Rate for Payer: Quartz Commercial |
$320.34
|
| Rate for Payer: The Alliance Commercial |
$281.00
|
| Rate for Payer: United Healthcare Medicaid |
$134.77
|
| Rate for Payer: WEA Trust Commercial |
$309.10
|
| Rate for Payer: WPS Commercial |
$416.27
|
|
|
Excise Mandible Lesion 21040
|
Professional
|
Both
|
$2,016.00
|
|
|
Service Code
|
CPT 21040
|
| Hospital Charge Code |
4157351
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$376.66 |
| Max. Negotiated Rate |
$1,915.20 |
| Rate for Payer: Aetna Commercial |
$1,915.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,733.76
|
| Rate for Payer: Cash Price |
$604.80
|
| Rate for Payer: Cash Price |
$604.80
|
| Rate for Payer: Cigna Commercial |
$1,915.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$376.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,209.60
|
| Rate for Payer: Health EOS Commercial |
$1,834.56
|
| Rate for Payer: HFN Commercial |
$1,915.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,270.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,270.94
|
| Rate for Payer: Multiplan Commercial |
$1,612.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,915.20
|
| Rate for Payer: Quartz Beloit One Network |
$887.04
|
| Rate for Payer: Quartz Commercial |
$1,149.12
|
| Rate for Payer: The Alliance Commercial |
$1,008.00
|
| Rate for Payer: United Healthcare Medicaid |
$376.66
|
| Rate for Payer: WEA Trust Commercial |
$1,108.80
|
| Rate for Payer: WPS Commercial |
$1,493.25
|
|
