|
INSERT NEEDLE W/O INJ 3 OR MORE MUSCLES 20561
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
CPT 20561
|
| Hospital Charge Code |
5565249
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.68 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Aetna Commercial |
$92.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$88.27
|
| Rate for Payer: HFN Commercial |
$92.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$82.64
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.15
|
| Rate for Payer: Quartz Beloit One Network |
$42.68
|
| Rate for Payer: Quartz Commercial |
$55.29
|
| Rate for Payer: The Alliance Commercial |
$48.50
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
Insert new site - IABP Activity
|
Facility
|
IP
|
$12,061.00
|
|
|
Service Code
|
CPT 33967
|
| Hospital Charge Code |
3034566
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$5,909.89 |
| Max. Negotiated Rate |
$11,096.12 |
| Rate for Payer: Aetna Commercial |
$10,854.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,372.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,392.33
|
| Rate for Payer: Cash Price |
$3,618.30
|
| Rate for Payer: Cigna Commercial |
$11,096.12
|
| Rate for Payer: Health EOS Commercial |
$10,734.29
|
| Rate for Payer: HFN Commercial |
$11,096.12
|
| Rate for Payer: Multiplan Commercial |
$9,648.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,236.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,096.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,909.89
|
| Rate for Payer: Quartz Commercial |
$7,236.60
|
| Rate for Payer: WEA Trust Commercial |
$6,633.55
|
| Rate for Payer: WPS Commercial |
$8,933.58
|
|
|
Insert new site - IABP Activity
|
Facility
|
OP
|
$12,061.00
|
|
|
Service Code
|
CPT 33967
|
| Hospital Charge Code |
3034566
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$3,377.08 |
| Max. Negotiated Rate |
$48,244.00 |
| Rate for Payer: Aetna Commercial |
$10,854.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,372.46
|
| Rate for Payer: Aetna Managed Medicare |
$3,377.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,839.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,030.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,789.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,392.33
|
| Rate for Payer: Cash Price |
$3,618.30
|
| Rate for Payer: Cash Price |
$3,618.30
|
| Rate for Payer: Cigna Commercial |
$11,096.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$10,734.29
|
| Rate for Payer: HFN Commercial |
$11,096.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,045.75
|
| Rate for Payer: Multiplan Commercial |
$9,648.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,236.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,096.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,909.89
|
| Rate for Payer: Quartz Commercial |
$7,839.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,236.60
|
| Rate for Payer: The Alliance Commercial |
$48,244.00
|
| Rate for Payer: United Healthcare PPO |
$9,045.75
|
| Rate for Payer: WEA Trust Commercial |
$6,633.55
|
| Rate for Payer: WPS Commercial |
$8,933.58
|
|
|
INSERT NON-TUNNEL CV CATH 36555
|
Professional
|
Both
|
$1,715.00
|
|
|
Service Code
|
CPT 36555
|
| Hospital Charge Code |
3014530
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$247.43 |
| Max. Negotiated Rate |
$1,629.25 |
| Rate for Payer: Aetna Commercial |
$1,629.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,474.90
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cigna Commercial |
$1,629.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$247.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,029.00
|
| Rate for Payer: Health EOS Commercial |
$1,560.65
|
| Rate for Payer: HFN Commercial |
$1,629.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$286.11
|
| Rate for Payer: Multiplan Commercial |
$1,372.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,629.25
|
| Rate for Payer: Quartz Beloit One Network |
$754.60
|
| Rate for Payer: Quartz Commercial |
$977.55
|
| Rate for Payer: The Alliance Commercial |
$857.50
|
| Rate for Payer: United Healthcare Medicaid |
$247.43
|
| Rate for Payer: WEA Trust Commercial |
$943.25
|
| Rate for Payer: WPS Commercial |
$1,270.30
|
|
|
INSERT NON-TUNNEL CV CATH 36556
|
Professional
|
Both
|
$759.00
|
|
|
Service Code
|
CPT 36556
|
| Hospital Charge Code |
3014531
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$210.89 |
| Max. Negotiated Rate |
$721.05 |
| Rate for Payer: Aetna Commercial |
$721.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$652.74
|
| Rate for Payer: Cash Price |
$227.70
|
| Rate for Payer: Cash Price |
$227.70
|
| Rate for Payer: Cash Price |
$227.70
|
| Rate for Payer: Cigna Commercial |
$721.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$455.40
|
| Rate for Payer: Health EOS Commercial |
$690.69
|
| Rate for Payer: HFN Commercial |
$721.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$281.24
|
| Rate for Payer: Multiplan Commercial |
$607.20
|
| Rate for Payer: Preferred Network Access Commercial |
$721.05
|
| Rate for Payer: Quartz Beloit One Network |
$333.96
|
| Rate for Payer: Quartz Commercial |
$432.63
|
| Rate for Payer: The Alliance Commercial |
$379.50
|
| Rate for Payer: United Healthcare Medicaid |
$210.89
|
| Rate for Payer: WEA Trust Commercial |
$417.45
|
| Rate for Payer: WPS Commercial |
$562.19
|
|
|
Insert Non-Tunnel CV Cath 3655622
|
Professional
|
Both
|
$911.00
|
|
|
Service Code
|
CPT 36556 22
|
| Hospital Charge Code |
5478734
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$210.89 |
| Max. Negotiated Rate |
$865.45 |
| Rate for Payer: Aetna Commercial |
$865.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$783.46
|
| Rate for Payer: Cash Price |
$273.30
|
| Rate for Payer: Cash Price |
$273.30
|
| Rate for Payer: Cash Price |
$273.30
|
| Rate for Payer: Cigna Commercial |
$865.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$546.60
|
| Rate for Payer: Health EOS Commercial |
$829.01
|
| Rate for Payer: HFN Commercial |
$865.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$281.24
|
| Rate for Payer: Multiplan Commercial |
$728.80
|
| Rate for Payer: Preferred Network Access Commercial |
$865.45
|
| Rate for Payer: Quartz Beloit One Network |
$400.84
|
| Rate for Payer: Quartz Commercial |
$519.27
|
| Rate for Payer: The Alliance Commercial |
$455.50
|
| Rate for Payer: United Healthcare Medicaid |
$210.89
|
| Rate for Payer: WEA Trust Commercial |
$501.05
|
| Rate for Payer: WPS Commercial |
$674.78
|
|
|
Insert Non-Tunnel CV Cath 3655626
|
Professional
|
Both
|
$759.00
|
|
|
Service Code
|
CPT 36556 26
|
| Hospital Charge Code |
4163454
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$210.89 |
| Max. Negotiated Rate |
$721.05 |
| Rate for Payer: Aetna Commercial |
$721.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$652.74
|
| Rate for Payer: Cash Price |
$227.70
|
| Rate for Payer: Cash Price |
$227.70
|
| Rate for Payer: Cash Price |
$227.70
|
| Rate for Payer: Cigna Commercial |
$721.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$455.40
|
| Rate for Payer: Health EOS Commercial |
$690.69
|
| Rate for Payer: HFN Commercial |
$721.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$281.24
|
| Rate for Payer: Multiplan Commercial |
$607.20
|
| Rate for Payer: Preferred Network Access Commercial |
$721.05
|
| Rate for Payer: Quartz Beloit One Network |
$333.96
|
| Rate for Payer: Quartz Commercial |
$432.63
|
| Rate for Payer: The Alliance Commercial |
$379.50
|
| Rate for Payer: United Healthcare Medicaid |
$210.89
|
| Rate for Payer: WEA Trust Commercial |
$417.45
|
| Rate for Payer: WPS Commercial |
$562.19
|
|
|
INSERT OCTOBASE RETRACTOR 28707
|
Facility
|
IP
|
$986.00
|
|
| Hospital Charge Code |
2965340
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$483.14 |
| Max. Negotiated Rate |
$907.12 |
| Rate for Payer: Aetna Commercial |
$887.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$847.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$522.58
|
| Rate for Payer: Cash Price |
$295.80
|
| Rate for Payer: Cigna Commercial |
$907.12
|
| Rate for Payer: Health EOS Commercial |
$877.54
|
| Rate for Payer: HFN Commercial |
$907.12
|
| Rate for Payer: Multiplan Commercial |
$788.80
|
| Rate for Payer: NAPHCARE Commercial |
$591.60
|
| Rate for Payer: Preferred Network Access Commercial |
$907.12
|
| Rate for Payer: Quartz Beloit One Network |
$483.14
|
| Rate for Payer: Quartz Commercial |
$591.60
|
| Rate for Payer: WEA Trust Commercial |
$542.30
|
| Rate for Payer: WPS Commercial |
$730.33
|
|
|
INSERT OCTOBASE RETRACTOR 28707
|
Facility
|
OP
|
$986.00
|
|
| Hospital Charge Code |
2965340
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$276.08 |
| Max. Negotiated Rate |
$3,944.00 |
| Rate for Payer: Aetna Commercial |
$887.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$847.96
|
| Rate for Payer: Aetna Managed Medicare |
$276.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$640.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$493.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$473.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$522.58
|
| Rate for Payer: Cash Price |
$295.80
|
| Rate for Payer: Cigna Commercial |
$907.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$551.77
|
| Rate for Payer: Health EOS Commercial |
$877.54
|
| Rate for Payer: HFN Commercial |
$907.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$739.50
|
| Rate for Payer: Multiplan Commercial |
$788.80
|
| Rate for Payer: NAPHCARE Commercial |
$591.60
|
| Rate for Payer: Preferred Network Access Commercial |
$907.12
|
| Rate for Payer: Quartz Beloit One Network |
$483.14
|
| Rate for Payer: Quartz Commercial |
$640.90
|
| Rate for Payer: Quartz Medicare Advantage |
$591.60
|
| Rate for Payer: The Alliance Commercial |
$3,944.00
|
| Rate for Payer: WEA Trust Commercial |
$542.30
|
| Rate for Payer: WPS Commercial |
$730.33
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING LT MEDIAL LG 3MM 159554
|
Facility
|
OP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6180241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,450.96 |
| Max. Negotiated Rate |
$20,728.00 |
| Rate for Payer: Aetna Commercial |
$4,663.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,456.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,450.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,368.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,591.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,487.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,746.46
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,767.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,899.85
|
| Rate for Payer: Health EOS Commercial |
$4,611.98
|
| Rate for Payer: HFN Commercial |
$4,767.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,886.50
|
| Rate for Payer: Multiplan Commercial |
$4,145.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,767.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,539.18
|
| Rate for Payer: Quartz Commercial |
$3,368.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,109.20
|
| Rate for Payer: The Alliance Commercial |
$20,728.00
|
| Rate for Payer: WEA Trust Commercial |
$2,850.10
|
| Rate for Payer: WPS Commercial |
$3,838.31
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING LT MEDIAL LG 3MM 159554
|
Facility
|
IP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6180241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,539.18 |
| Max. Negotiated Rate |
$4,767.44 |
| Rate for Payer: Aetna Commercial |
$4,663.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,456.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,746.46
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,767.44
|
| Rate for Payer: Health EOS Commercial |
$4,611.98
|
| Rate for Payer: HFN Commercial |
$4,767.44
|
| Rate for Payer: Multiplan Commercial |
$4,145.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,767.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,539.18
|
| Rate for Payer: Quartz Commercial |
$3,109.20
|
| Rate for Payer: WEA Trust Commercial |
$2,850.10
|
| Rate for Payer: WPS Commercial |
$3,838.31
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING LT MEDIAL MED 3MM 159547
|
Facility
|
IP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181460
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,539.18 |
| Max. Negotiated Rate |
$4,767.44 |
| Rate for Payer: Aetna Commercial |
$4,663.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,456.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,746.46
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,767.44
|
| Rate for Payer: Health EOS Commercial |
$4,611.98
|
| Rate for Payer: HFN Commercial |
$4,767.44
|
| Rate for Payer: Multiplan Commercial |
$4,145.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,767.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,539.18
|
| Rate for Payer: Quartz Commercial |
$3,109.20
|
| Rate for Payer: WEA Trust Commercial |
$2,850.10
|
| Rate for Payer: WPS Commercial |
$3,838.31
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING LT MEDIAL MED 3MM 159547
|
Facility
|
OP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6181460
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,450.96 |
| Max. Negotiated Rate |
$20,728.00 |
| Rate for Payer: Aetna Commercial |
$4,663.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,456.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,450.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,368.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,591.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,487.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,746.46
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,767.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,899.85
|
| Rate for Payer: Health EOS Commercial |
$4,611.98
|
| Rate for Payer: HFN Commercial |
$4,767.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,886.50
|
| Rate for Payer: Multiplan Commercial |
$4,145.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,767.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,539.18
|
| Rate for Payer: Quartz Commercial |
$3,368.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,109.20
|
| Rate for Payer: The Alliance Commercial |
$20,728.00
|
| Rate for Payer: WEA Trust Commercial |
$2,850.10
|
| Rate for Payer: WPS Commercial |
$3,838.31
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING LT MEDIAL MED 4MM 159548
|
Facility
|
IP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,746.45 |
| Max. Negotiated Rate |
$5,156.60 |
| Rate for Payer: Aetna Commercial |
$5,044.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,820.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,970.65
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,156.60
|
| Rate for Payer: Health EOS Commercial |
$4,988.45
|
| Rate for Payer: HFN Commercial |
$5,156.60
|
| Rate for Payer: Multiplan Commercial |
$4,484.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,156.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,746.45
|
| Rate for Payer: Quartz Commercial |
$3,363.00
|
| Rate for Payer: WEA Trust Commercial |
$3,082.75
|
| Rate for Payer: WPS Commercial |
$4,151.62
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING LT MEDIAL MED 4MM 159548
|
Facility
|
OP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,569.40 |
| Max. Negotiated Rate |
$22,420.00 |
| Rate for Payer: Aetna Commercial |
$5,044.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,820.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,569.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,643.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,802.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,690.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,970.65
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,156.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,136.56
|
| Rate for Payer: Health EOS Commercial |
$4,988.45
|
| Rate for Payer: HFN Commercial |
$5,156.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,203.75
|
| Rate for Payer: Multiplan Commercial |
$4,484.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,156.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,746.45
|
| Rate for Payer: Quartz Commercial |
$3,643.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,363.00
|
| Rate for Payer: The Alliance Commercial |
$22,420.00
|
| Rate for Payer: WEA Trust Commercial |
$3,082.75
|
| Rate for Payer: WPS Commercial |
$4,151.62
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING LT MEDIAL MED 5MM 159549
|
Facility
|
OP
|
$5,829.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,632.12 |
| Max. Negotiated Rate |
$23,316.00 |
| Rate for Payer: Aetna Commercial |
$5,246.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,012.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,632.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,788.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,914.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,797.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.37
|
| Rate for Payer: Cash Price |
$1,748.70
|
| Rate for Payer: Cigna Commercial |
$5,362.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,261.91
|
| Rate for Payer: Health EOS Commercial |
$5,187.81
|
| Rate for Payer: HFN Commercial |
$5,362.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,371.75
|
| Rate for Payer: Multiplan Commercial |
$4,663.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.21
|
| Rate for Payer: Quartz Commercial |
$3,788.85
|
| Rate for Payer: Quartz Medicare Advantage |
$3,497.40
|
| Rate for Payer: The Alliance Commercial |
$23,316.00
|
| Rate for Payer: WEA Trust Commercial |
$3,205.95
|
| Rate for Payer: WPS Commercial |
$4,317.54
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING LT MEDIAL MED 5MM 159549
|
Facility
|
IP
|
$5,829.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5456775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,856.21 |
| Max. Negotiated Rate |
$5,362.68 |
| Rate for Payer: Aetna Commercial |
$5,246.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,012.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.37
|
| Rate for Payer: Cash Price |
$1,748.70
|
| Rate for Payer: Cigna Commercial |
$5,362.68
|
| Rate for Payer: Health EOS Commercial |
$5,187.81
|
| Rate for Payer: HFN Commercial |
$5,362.68
|
| Rate for Payer: Multiplan Commercial |
$4,663.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.21
|
| Rate for Payer: Quartz Commercial |
$3,497.40
|
| Rate for Payer: WEA Trust Commercial |
$3,205.95
|
| Rate for Payer: WPS Commercial |
$4,317.54
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL 3MM 159575
|
Facility
|
OP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5107250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,569.40 |
| Max. Negotiated Rate |
$22,420.00 |
| Rate for Payer: Aetna Commercial |
$5,044.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,820.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,569.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,643.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,802.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,690.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,970.65
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,156.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,136.56
|
| Rate for Payer: Health EOS Commercial |
$4,988.45
|
| Rate for Payer: HFN Commercial |
$5,156.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,203.75
|
| Rate for Payer: Multiplan Commercial |
$4,484.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,156.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,746.45
|
| Rate for Payer: Quartz Commercial |
$3,643.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,363.00
|
| Rate for Payer: The Alliance Commercial |
$22,420.00
|
| Rate for Payer: WEA Trust Commercial |
$3,082.75
|
| Rate for Payer: WPS Commercial |
$4,151.62
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL 3MM 159575
|
Facility
|
IP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5107250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,746.45 |
| Max. Negotiated Rate |
$5,156.60 |
| Rate for Payer: Aetna Commercial |
$5,044.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,820.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,970.65
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,156.60
|
| Rate for Payer: Health EOS Commercial |
$4,988.45
|
| Rate for Payer: HFN Commercial |
$5,156.60
|
| Rate for Payer: Multiplan Commercial |
$4,484.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,156.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,746.45
|
| Rate for Payer: Quartz Commercial |
$3,363.00
|
| Rate for Payer: WEA Trust Commercial |
$3,082.75
|
| Rate for Payer: WPS Commercial |
$4,151.62
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL 4MM 159576
|
Facility
|
IP
|
$5,829.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998773
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,856.21 |
| Max. Negotiated Rate |
$5,362.68 |
| Rate for Payer: Aetna Commercial |
$5,246.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,012.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.37
|
| Rate for Payer: Cash Price |
$1,748.70
|
| Rate for Payer: Cigna Commercial |
$5,362.68
|
| Rate for Payer: Health EOS Commercial |
$5,187.81
|
| Rate for Payer: HFN Commercial |
$5,362.68
|
| Rate for Payer: Multiplan Commercial |
$4,663.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.21
|
| Rate for Payer: Quartz Commercial |
$3,497.40
|
| Rate for Payer: WEA Trust Commercial |
$3,205.95
|
| Rate for Payer: WPS Commercial |
$4,317.54
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL 4MM 159576
|
Facility
|
OP
|
$5,829.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998773
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,632.12 |
| Max. Negotiated Rate |
$23,316.00 |
| Rate for Payer: Aetna Commercial |
$5,246.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,012.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,632.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,788.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,914.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,797.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.37
|
| Rate for Payer: Cash Price |
$1,748.70
|
| Rate for Payer: Cigna Commercial |
$5,362.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,261.91
|
| Rate for Payer: Health EOS Commercial |
$5,187.81
|
| Rate for Payer: HFN Commercial |
$5,362.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,371.75
|
| Rate for Payer: Multiplan Commercial |
$4,663.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.21
|
| Rate for Payer: Quartz Commercial |
$3,788.85
|
| Rate for Payer: Quartz Medicare Advantage |
$3,497.40
|
| Rate for Payer: The Alliance Commercial |
$23,316.00
|
| Rate for Payer: WEA Trust Commercial |
$3,205.95
|
| Rate for Payer: WPS Commercial |
$4,317.54
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL 5MM 159577
|
Facility
|
OP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,569.40 |
| Max. Negotiated Rate |
$22,420.00 |
| Rate for Payer: Aetna Commercial |
$5,044.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,820.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,569.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,643.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,802.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,690.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,970.65
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,156.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,136.56
|
| Rate for Payer: Health EOS Commercial |
$4,988.45
|
| Rate for Payer: HFN Commercial |
$5,156.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,203.75
|
| Rate for Payer: Multiplan Commercial |
$4,484.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,156.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,746.45
|
| Rate for Payer: Quartz Commercial |
$3,643.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,363.00
|
| Rate for Payer: The Alliance Commercial |
$22,420.00
|
| Rate for Payer: WEA Trust Commercial |
$3,082.75
|
| Rate for Payer: WPS Commercial |
$4,151.62
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL 5MM 159577
|
Facility
|
IP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5074916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,746.45 |
| Max. Negotiated Rate |
$5,156.60 |
| Rate for Payer: Aetna Commercial |
$5,044.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,820.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,970.65
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,156.60
|
| Rate for Payer: Health EOS Commercial |
$4,988.45
|
| Rate for Payer: HFN Commercial |
$5,156.60
|
| Rate for Payer: Multiplan Commercial |
$4,484.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,156.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,746.45
|
| Rate for Payer: Quartz Commercial |
$3,363.00
|
| Rate for Payer: WEA Trust Commercial |
$3,082.75
|
| Rate for Payer: WPS Commercial |
$4,151.62
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL LG 3MM 159582
|
Facility
|
IP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106943
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,746.45 |
| Max. Negotiated Rate |
$5,156.60 |
| Rate for Payer: Aetna Commercial |
$5,044.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,820.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,970.65
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,156.60
|
| Rate for Payer: Health EOS Commercial |
$4,988.45
|
| Rate for Payer: HFN Commercial |
$5,156.60
|
| Rate for Payer: Multiplan Commercial |
$4,484.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,156.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,746.45
|
| Rate for Payer: Quartz Commercial |
$3,363.00
|
| Rate for Payer: WEA Trust Commercial |
$3,082.75
|
| Rate for Payer: WPS Commercial |
$4,151.62
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL LG 3MM 159582
|
Facility
|
OP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5106943
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,569.40 |
| Max. Negotiated Rate |
$22,420.00 |
| Rate for Payer: Aetna Commercial |
$5,044.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,820.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,569.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,643.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,802.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,690.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,970.65
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,156.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,136.56
|
| Rate for Payer: Health EOS Commercial |
$4,988.45
|
| Rate for Payer: HFN Commercial |
$5,156.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,203.75
|
| Rate for Payer: Multiplan Commercial |
$4,484.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,363.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,156.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,746.45
|
| Rate for Payer: Quartz Commercial |
$3,643.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,363.00
|
| Rate for Payer: The Alliance Commercial |
$22,420.00
|
| Rate for Payer: WEA Trust Commercial |
$3,082.75
|
| Rate for Payer: WPS Commercial |
$4,151.62
|
|
