|
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 |
$824.93 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Aetna Commercial |
$11,289.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,787.36
|
| Rate for Payer: Aetna Managed Medicare |
$3,512.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,153.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,271.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,020.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,648.02
|
| Rate for Payer: Cash Price |
$3,618.30
|
| Rate for Payer: Cash Price |
$3,618.30
|
| Rate for Payer: Cigna Commercial |
$11,539.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$11,163.66
|
| Rate for Payer: HFN Commercial |
$11,539.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,407.58
|
| Rate for Payer: Multiplan Commercial |
$10,034.75
|
| Rate for Payer: NAPHCARE Commercial |
$7,526.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,539.96
|
| Rate for Payer: Quartz Beloit One Network |
$6,146.29
|
| Rate for Payer: Quartz Commercial |
$8,153.24
|
| Rate for Payer: Quartz Medicare Advantage |
$7,526.06
|
| Rate for Payer: The Alliance Commercial |
$824.93
|
| Rate for Payer: United Healthcare PPO |
$9,407.58
|
| Rate for Payer: WEA Trust Commercial |
$6,898.89
|
| Rate for Payer: WPS Commercial |
$9,290.59
|
|
|
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 |
$78.00 |
| Max. Negotiated Rate |
$1,694.42 |
| Rate for Payer: Aetna Commercial |
$1,694.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,533.90
|
| Rate for Payer: Aetna Managed Medicare |
$78.00
|
| Rate for Payer: Anthem Medicare Advantage |
$78.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$78.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$78.00
|
| 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 |
$1,694.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$257.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.00
|
| Rate for Payer: Health EOS Commercial |
$1,623.08
|
| Rate for Payer: HFN Commercial |
$1,694.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$297.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$297.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$1,426.88
|
| Rate for Payer: NAPHCARE Commercial |
$117.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,694.42
|
| Rate for Payer: Quartz Beloit One Network |
$784.78
|
| Rate for Payer: Quartz Commercial |
$1,016.65
|
| Rate for Payer: Quartz Medicare Advantage |
$78.00
|
| Rate for Payer: The Alliance Commercial |
$331.50
|
| Rate for Payer: United Healthcare Medicaid |
$257.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$980.98
|
| Rate for Payer: WPS Commercial |
$351.00
|
|
|
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 |
$74.51 |
| Max. Negotiated Rate |
$749.89 |
| Rate for Payer: Aetna Commercial |
$749.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$678.85
|
| Rate for Payer: Aetna Managed Medicare |
$74.51
|
| Rate for Payer: Anthem Medicare Advantage |
$74.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$74.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$74.51
|
| 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 |
$749.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$219.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.51
|
| Rate for Payer: Health EOS Commercial |
$718.32
|
| Rate for Payer: HFN Commercial |
$749.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$292.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$74.51
|
| Rate for Payer: Multiplan Commercial |
$631.49
|
| Rate for Payer: NAPHCARE Commercial |
$111.76
|
| Rate for Payer: Preferred Network Access Commercial |
$749.89
|
| Rate for Payer: Quartz Beloit One Network |
$347.32
|
| Rate for Payer: Quartz Commercial |
$449.94
|
| Rate for Payer: Quartz Medicare Advantage |
$74.51
|
| Rate for Payer: The Alliance Commercial |
$316.65
|
| Rate for Payer: United Healthcare Medicaid |
$219.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.51
|
| Rate for Payer: WEA Trust Commercial |
$434.15
|
| Rate for Payer: WPS Commercial |
$335.28
|
|
|
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 |
$219.33 |
| Max. Negotiated Rate |
$900.07 |
| Rate for Payer: Aetna Commercial |
$900.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$814.80
|
| 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 |
$900.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$219.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$568.46
|
| Rate for Payer: Health EOS Commercial |
$862.17
|
| Rate for Payer: HFN Commercial |
$900.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$292.49
|
| Rate for Payer: Multiplan Commercial |
$757.95
|
| Rate for Payer: Preferred Network Access Commercial |
$900.07
|
| Rate for Payer: Quartz Beloit One Network |
$416.87
|
| Rate for Payer: Quartz Commercial |
$540.04
|
| Rate for Payer: The Alliance Commercial |
$473.72
|
| Rate for Payer: United Healthcare Medicaid |
$219.33
|
| Rate for Payer: WEA Trust Commercial |
$521.09
|
| Rate for Payer: WPS Commercial |
$701.74
|
|
|
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 |
$219.33 |
| Max. Negotiated Rate |
$749.89 |
| Rate for Payer: Aetna Commercial |
$749.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$678.85
|
| 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 |
$749.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$219.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$473.62
|
| Rate for Payer: Health EOS Commercial |
$718.32
|
| Rate for Payer: HFN Commercial |
$749.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$292.49
|
| Rate for Payer: Multiplan Commercial |
$631.49
|
| Rate for Payer: Preferred Network Access Commercial |
$749.89
|
| Rate for Payer: Quartz Beloit One Network |
$347.32
|
| Rate for Payer: Quartz Commercial |
$449.94
|
| Rate for Payer: The Alliance Commercial |
$394.68
|
| Rate for Payer: United Healthcare Medicaid |
$219.33
|
| Rate for Payer: WEA Trust Commercial |
$434.15
|
| Rate for Payer: WPS Commercial |
$584.66
|
|
|
INSERT OCTOBASE RETRACTOR 28707
|
Facility
|
IP
|
$986.00
|
|
| Hospital Charge Code |
2965340
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$502.47 |
| Max. Negotiated Rate |
$943.40 |
| Rate for Payer: Aetna Commercial |
$922.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$881.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$543.48
|
| Rate for Payer: Cash Price |
$295.80
|
| Rate for Payer: Cigna Commercial |
$943.40
|
| Rate for Payer: Health EOS Commercial |
$912.64
|
| Rate for Payer: HFN Commercial |
$943.40
|
| Rate for Payer: Multiplan Commercial |
$820.35
|
| Rate for Payer: Preferred Network Access Commercial |
$943.40
|
| Rate for Payer: Quartz Beloit One Network |
$502.47
|
| Rate for Payer: Quartz Commercial |
$615.26
|
| Rate for Payer: WEA Trust Commercial |
$563.99
|
| Rate for Payer: WPS Commercial |
$759.52
|
|
|
INSERT OCTOBASE RETRACTOR 28707
|
Facility
|
OP
|
$986.00
|
|
| Hospital Charge Code |
2965340
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$287.12 |
| Max. Negotiated Rate |
$943.40 |
| Rate for Payer: Aetna Commercial |
$922.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$881.88
|
| Rate for Payer: Aetna Managed Medicare |
$287.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$666.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$512.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$492.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$543.48
|
| Rate for Payer: Cash Price |
$295.80
|
| Rate for Payer: Cigna Commercial |
$943.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$573.85
|
| Rate for Payer: Health EOS Commercial |
$912.64
|
| Rate for Payer: HFN Commercial |
$943.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$769.08
|
| Rate for Payer: Multiplan Commercial |
$820.35
|
| Rate for Payer: NAPHCARE Commercial |
$615.26
|
| Rate for Payer: Preferred Network Access Commercial |
$943.40
|
| Rate for Payer: Quartz Beloit One Network |
$502.47
|
| Rate for Payer: Quartz Commercial |
$666.54
|
| Rate for Payer: Quartz Medicare Advantage |
$615.26
|
| Rate for Payer: The Alliance Commercial |
$512.72
|
| Rate for Payer: WEA Trust Commercial |
$563.99
|
| Rate for Payer: WPS Commercial |
$759.52
|
|
|
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 |
$2,640.75 |
| Max. Negotiated Rate |
$4,958.14 |
| Rate for Payer: Aetna Commercial |
$4,850.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,634.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,856.32
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,958.14
|
| Rate for Payer: Health EOS Commercial |
$4,796.46
|
| Rate for Payer: HFN Commercial |
$4,958.14
|
| Rate for Payer: Multiplan Commercial |
$4,311.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,958.14
|
| Rate for Payer: Quartz Beloit One Network |
$2,640.75
|
| Rate for Payer: Quartz Commercial |
$3,233.57
|
| Rate for Payer: WEA Trust Commercial |
$2,964.10
|
| Rate for Payer: WPS Commercial |
$3,991.69
|
|
|
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 |
$1,509.00 |
| Max. Negotiated Rate |
$4,958.14 |
| Rate for Payer: Aetna Commercial |
$4,850.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,634.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,509.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,503.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,694.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,586.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,856.32
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,958.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,015.92
|
| Rate for Payer: Health EOS Commercial |
$4,796.46
|
| Rate for Payer: HFN Commercial |
$4,958.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,041.96
|
| Rate for Payer: Multiplan Commercial |
$4,311.42
|
| Rate for Payer: NAPHCARE Commercial |
$3,233.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,958.14
|
| Rate for Payer: Quartz Beloit One Network |
$2,640.75
|
| Rate for Payer: Quartz Commercial |
$3,503.03
|
| Rate for Payer: Quartz Medicare Advantage |
$3,233.57
|
| Rate for Payer: The Alliance Commercial |
$2,694.64
|
| Rate for Payer: WEA Trust Commercial |
$2,964.10
|
| Rate for Payer: WPS Commercial |
$3,991.69
|
|
|
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 |
$1,509.00 |
| Max. Negotiated Rate |
$4,958.14 |
| Rate for Payer: Health EOS Commercial |
$4,796.46
|
| Rate for Payer: Aetna Commercial |
$4,850.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,634.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,509.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,503.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,694.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,586.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,856.32
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,958.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,015.92
|
| Rate for Payer: HFN Commercial |
$4,958.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,041.96
|
| Rate for Payer: Multiplan Commercial |
$4,311.42
|
| Rate for Payer: NAPHCARE Commercial |
$3,233.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,958.14
|
| Rate for Payer: Quartz Beloit One Network |
$2,640.75
|
| Rate for Payer: Quartz Commercial |
$3,503.03
|
| Rate for Payer: Quartz Medicare Advantage |
$3,233.57
|
| Rate for Payer: The Alliance Commercial |
$2,694.64
|
| Rate for Payer: WEA Trust Commercial |
$2,964.10
|
| Rate for Payer: WPS Commercial |
$3,991.69
|
|
|
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 |
$2,640.75 |
| Max. Negotiated Rate |
$4,958.14 |
| Rate for Payer: Aetna Commercial |
$4,850.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,634.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,856.32
|
| Rate for Payer: Cash Price |
$1,554.60
|
| Rate for Payer: Cigna Commercial |
$4,958.14
|
| Rate for Payer: Health EOS Commercial |
$4,796.46
|
| Rate for Payer: HFN Commercial |
$4,958.14
|
| Rate for Payer: Multiplan Commercial |
$4,311.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,958.14
|
| Rate for Payer: Quartz Beloit One Network |
$2,640.75
|
| Rate for Payer: Quartz Commercial |
$3,233.57
|
| Rate for Payer: WEA Trust Commercial |
$2,964.10
|
| Rate for Payer: WPS Commercial |
$3,991.69
|
|
|
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 |
$1,632.18 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Aetna Managed Medicare |
$1,632.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,788.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,914.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,798.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,262.11
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,371.90
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.52
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,788.98
|
| Rate for Payer: Quartz Medicare Advantage |
$3,497.52
|
| Rate for Payer: The Alliance Commercial |
$2,914.60
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
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 |
$2,856.31 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,497.52
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
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 |
$1,697.40 |
| Max. Negotiated Rate |
$5,577.19 |
| Rate for Payer: Aetna Commercial |
$5,455.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,213.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,697.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,940.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,031.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,909.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,212.94
|
| Rate for Payer: Cash Price |
$1,748.70
|
| Rate for Payer: Cigna Commercial |
$5,577.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,392.48
|
| Rate for Payer: Health EOS Commercial |
$5,395.32
|
| Rate for Payer: HFN Commercial |
$5,577.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,546.62
|
| Rate for Payer: Multiplan Commercial |
$4,849.73
|
| Rate for Payer: NAPHCARE Commercial |
$3,637.30
|
| Rate for Payer: Preferred Network Access Commercial |
$5,577.19
|
| Rate for Payer: Quartz Beloit One Network |
$2,970.46
|
| Rate for Payer: Quartz Commercial |
$3,940.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,637.30
|
| Rate for Payer: The Alliance Commercial |
$3,031.08
|
| Rate for Payer: WEA Trust Commercial |
$3,334.19
|
| Rate for Payer: WPS Commercial |
$4,490.08
|
|
|
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 |
$2,970.46 |
| Max. Negotiated Rate |
$5,577.19 |
| Rate for Payer: Aetna Commercial |
$5,455.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,213.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,212.94
|
| Rate for Payer: Cash Price |
$1,748.70
|
| Rate for Payer: Cigna Commercial |
$5,577.19
|
| Rate for Payer: Health EOS Commercial |
$5,395.32
|
| Rate for Payer: HFN Commercial |
$5,577.19
|
| Rate for Payer: Multiplan Commercial |
$4,849.73
|
| Rate for Payer: Preferred Network Access Commercial |
$5,577.19
|
| Rate for Payer: Quartz Beloit One Network |
$2,970.46
|
| Rate for Payer: Quartz Commercial |
$3,637.30
|
| Rate for Payer: WEA Trust Commercial |
$3,334.19
|
| Rate for Payer: WPS Commercial |
$4,490.08
|
|
|
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 |
$1,632.18 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Aetna Managed Medicare |
$1,632.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,788.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,914.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,798.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,262.11
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,371.90
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.52
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,788.98
|
| Rate for Payer: Quartz Medicare Advantage |
$3,497.52
|
| Rate for Payer: The Alliance Commercial |
$2,914.60
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
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 |
$2,856.31 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,497.52
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
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 |
$1,697.40 |
| Max. Negotiated Rate |
$5,577.19 |
| Rate for Payer: Aetna Commercial |
$5,455.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,213.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,697.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,940.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,031.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,909.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,212.94
|
| Rate for Payer: Cash Price |
$1,748.70
|
| Rate for Payer: Cigna Commercial |
$5,577.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,392.48
|
| Rate for Payer: Health EOS Commercial |
$5,395.32
|
| Rate for Payer: HFN Commercial |
$5,577.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,546.62
|
| Rate for Payer: Multiplan Commercial |
$4,849.73
|
| Rate for Payer: NAPHCARE Commercial |
$3,637.30
|
| Rate for Payer: Preferred Network Access Commercial |
$5,577.19
|
| Rate for Payer: Quartz Beloit One Network |
$2,970.46
|
| Rate for Payer: Quartz Commercial |
$3,940.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,637.30
|
| Rate for Payer: The Alliance Commercial |
$3,031.08
|
| Rate for Payer: WEA Trust Commercial |
$3,334.19
|
| Rate for Payer: WPS Commercial |
$4,490.08
|
|
|
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 |
$2,970.46 |
| Max. Negotiated Rate |
$5,577.19 |
| Rate for Payer: Aetna Commercial |
$5,455.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,213.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,212.94
|
| Rate for Payer: Cash Price |
$1,748.70
|
| Rate for Payer: Cigna Commercial |
$5,577.19
|
| Rate for Payer: Health EOS Commercial |
$5,395.32
|
| Rate for Payer: HFN Commercial |
$5,577.19
|
| Rate for Payer: Multiplan Commercial |
$4,849.73
|
| Rate for Payer: Preferred Network Access Commercial |
$5,577.19
|
| Rate for Payer: Quartz Beloit One Network |
$2,970.46
|
| Rate for Payer: Quartz Commercial |
$3,637.30
|
| Rate for Payer: WEA Trust Commercial |
$3,334.19
|
| Rate for Payer: WPS Commercial |
$4,490.08
|
|
|
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 |
$2,856.31 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,497.52
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
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 |
$1,632.18 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Aetna Managed Medicare |
$1,632.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,788.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,914.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,798.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,262.11
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,371.90
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.52
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,788.98
|
| Rate for Payer: Quartz Medicare Advantage |
$3,497.52
|
| Rate for Payer: The Alliance Commercial |
$2,914.60
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
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 |
$2,856.31 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,497.52
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
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 |
$1,632.18 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Aetna Managed Medicare |
$1,632.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,788.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,914.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,798.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,262.11
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,371.90
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.52
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,788.98
|
| Rate for Payer: Quartz Medicare Advantage |
$3,497.52
|
| Rate for Payer: The Alliance Commercial |
$2,914.60
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL LG 5MM 159584
|
Facility
|
IP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,856.31 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,497.52
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
|
INSERT OXFORD ANATOMIC MENISCAL BEARING RT MEDIAL LG 5MM 159584
|
Facility
|
OP
|
$5,605.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4998678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,632.18 |
| Max. Negotiated Rate |
$5,362.86 |
| Rate for Payer: Aetna Commercial |
$5,246.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,013.11
|
| Rate for Payer: Aetna Managed Medicare |
$1,632.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,788.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,914.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,798.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,089.48
|
| Rate for Payer: Cash Price |
$1,681.50
|
| Rate for Payer: Cigna Commercial |
$5,362.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,262.11
|
| Rate for Payer: Health EOS Commercial |
$5,187.99
|
| Rate for Payer: HFN Commercial |
$5,362.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,371.90
|
| Rate for Payer: Multiplan Commercial |
$4,663.36
|
| Rate for Payer: NAPHCARE Commercial |
$3,497.52
|
| Rate for Payer: Preferred Network Access Commercial |
$5,362.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,856.31
|
| Rate for Payer: Quartz Commercial |
$3,788.98
|
| Rate for Payer: Quartz Medicare Advantage |
$3,497.52
|
| Rate for Payer: The Alliance Commercial |
$2,914.60
|
| Rate for Payer: WEA Trust Commercial |
$3,206.06
|
| Rate for Payer: WPS Commercial |
$4,317.53
|
|
