|
Pediatric Ezio
|
Facility
|
OP
|
$231.00
|
|
| Hospital Charge Code |
3040372
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.68 |
| Max. Negotiated Rate |
$924.00 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.66
|
| Rate for Payer: Aetna Managed Medicare |
$64.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$110.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.43
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$212.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.27
|
| Rate for Payer: Health EOS Commercial |
$205.59
|
| Rate for Payer: HFN Commercial |
$212.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$173.25
|
| Rate for Payer: Multiplan Commercial |
$184.80
|
| Rate for Payer: NAPHCARE Commercial |
$138.60
|
| Rate for Payer: Preferred Network Access Commercial |
$212.52
|
| Rate for Payer: Quartz Beloit One Network |
$113.19
|
| Rate for Payer: Quartz Commercial |
$150.15
|
| Rate for Payer: Quartz Medicare Advantage |
$138.60
|
| Rate for Payer: The Alliance Commercial |
$924.00
|
| Rate for Payer: WEA Trust Commercial |
$127.05
|
| Rate for Payer: WPS Commercial |
$171.10
|
|
|
Pediatric Ezio
|
Facility
|
IP
|
$231.00
|
|
| Hospital Charge Code |
3040372
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.19 |
| Max. Negotiated Rate |
$212.52 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.43
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$212.52
|
| Rate for Payer: Health EOS Commercial |
$205.59
|
| Rate for Payer: HFN Commercial |
$212.52
|
| Rate for Payer: Multiplan Commercial |
$184.80
|
| Rate for Payer: NAPHCARE Commercial |
$138.60
|
| Rate for Payer: Preferred Network Access Commercial |
$212.52
|
| Rate for Payer: Quartz Beloit One Network |
$113.19
|
| Rate for Payer: Quartz Commercial |
$138.60
|
| Rate for Payer: WEA Trust Commercial |
$127.05
|
| Rate for Payer: WPS Commercial |
$171.10
|
|
|
PEDIFIX ARCH BINDER LARGE
|
Facility
|
OP
|
$233.00
|
|
| Hospital Charge Code |
2969827
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.24 |
| Max. Negotiated Rate |
$932.00 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Aetna Managed Medicare |
$65.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$151.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$116.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.49
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$214.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.39
|
| Rate for Payer: Health EOS Commercial |
$207.37
|
| Rate for Payer: HFN Commercial |
$214.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.75
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: NAPHCARE Commercial |
$139.80
|
| Rate for Payer: Preferred Network Access Commercial |
$214.36
|
| Rate for Payer: Quartz Beloit One Network |
$114.17
|
| Rate for Payer: Quartz Commercial |
$151.45
|
| Rate for Payer: Quartz Medicare Advantage |
$139.80
|
| Rate for Payer: The Alliance Commercial |
$932.00
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
PEDIFIX ARCH BINDER LARGE
|
Facility
|
IP
|
$233.00
|
|
| Hospital Charge Code |
2969827
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$114.17 |
| Max. Negotiated Rate |
$214.36 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.49
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$214.36
|
| Rate for Payer: Health EOS Commercial |
$207.37
|
| Rate for Payer: HFN Commercial |
$214.36
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: NAPHCARE Commercial |
$139.80
|
| Rate for Payer: Preferred Network Access Commercial |
$214.36
|
| Rate for Payer: Quartz Beloit One Network |
$114.17
|
| Rate for Payer: Quartz Commercial |
$139.80
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
PEDIFIX ARCH BINDER MEDIUM
|
Facility
|
OP
|
$233.00
|
|
| Hospital Charge Code |
2969828
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.24 |
| Max. Negotiated Rate |
$932.00 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Aetna Managed Medicare |
$65.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$151.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$116.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.49
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$214.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.39
|
| Rate for Payer: Health EOS Commercial |
$207.37
|
| Rate for Payer: HFN Commercial |
$214.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.75
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: NAPHCARE Commercial |
$139.80
|
| Rate for Payer: Preferred Network Access Commercial |
$214.36
|
| Rate for Payer: Quartz Beloit One Network |
$114.17
|
| Rate for Payer: Quartz Commercial |
$151.45
|
| Rate for Payer: Quartz Medicare Advantage |
$139.80
|
| Rate for Payer: The Alliance Commercial |
$932.00
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
PEDIFIX ARCH BINDER MEDIUM
|
Facility
|
IP
|
$233.00
|
|
| Hospital Charge Code |
2969828
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$114.17 |
| Max. Negotiated Rate |
$214.36 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.49
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$214.36
|
| Rate for Payer: Health EOS Commercial |
$207.37
|
| Rate for Payer: HFN Commercial |
$214.36
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: NAPHCARE Commercial |
$139.80
|
| Rate for Payer: Preferred Network Access Commercial |
$214.36
|
| Rate for Payer: Quartz Beloit One Network |
$114.17
|
| Rate for Payer: Quartz Commercial |
$139.80
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
PEDI-PAD ADHESIVE FOAM SZ 104 9204
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
2970945
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
PEDI-PAD ADHESIVE FOAM SZ 104 9204
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
2970945
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
PEDI PAD MOLESKIN 101-A
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
2970599
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
PEDI PAD MOLESKIN 101-A
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
2970599
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.68
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1.80
|
| Rate for Payer: The Alliance Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
Peds Observation Per Hour
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040433
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$37.20
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
Peds Observation Per Hour
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040433
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$6,992.00 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,992.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,030.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,729.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.70
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.50
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$40.30
|
| Rate for Payer: Quartz Medicare Advantage |
$37.20
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: United Healthcare PPO |
$2,598.00
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
PEG DRILL BIT INBONE TALAR 4MM IB200020
|
Facility
|
OP
|
$1,908.00
|
|
| Hospital Charge Code |
5831729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$534.24 |
| Max. Negotiated Rate |
$7,632.00 |
| Rate for Payer: Aetna Commercial |
$1,717.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,640.88
|
| Rate for Payer: Aetna Managed Medicare |
$534.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,240.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$954.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$915.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,011.24
|
| Rate for Payer: Cash Price |
$572.40
|
| Rate for Payer: Cigna Commercial |
$1,755.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,067.72
|
| Rate for Payer: Health EOS Commercial |
$1,698.12
|
| Rate for Payer: HFN Commercial |
$1,755.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,431.00
|
| Rate for Payer: Multiplan Commercial |
$1,526.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,144.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,755.36
|
| Rate for Payer: Quartz Beloit One Network |
$934.92
|
| Rate for Payer: Quartz Commercial |
$1,240.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,144.80
|
| Rate for Payer: The Alliance Commercial |
$7,632.00
|
| Rate for Payer: WEA Trust Commercial |
$1,049.40
|
| Rate for Payer: WPS Commercial |
$1,413.26
|
|
|
PEG DRILL BIT INBONE TALAR 4MM IB200020
|
Facility
|
IP
|
$1,908.00
|
|
| Hospital Charge Code |
5831729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$934.92 |
| Max. Negotiated Rate |
$1,755.36 |
| Rate for Payer: Aetna Commercial |
$1,717.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,640.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,011.24
|
| Rate for Payer: Cash Price |
$572.40
|
| Rate for Payer: Cigna Commercial |
$1,755.36
|
| Rate for Payer: Health EOS Commercial |
$1,698.12
|
| Rate for Payer: HFN Commercial |
$1,755.36
|
| Rate for Payer: Multiplan Commercial |
$1,526.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,144.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,755.36
|
| Rate for Payer: Quartz Beloit One Network |
$934.92
|
| Rate for Payer: Quartz Commercial |
$1,144.80
|
| Rate for Payer: WEA Trust Commercial |
$1,049.40
|
| Rate for Payer: WPS Commercial |
$1,413.26
|
|
|
PEG TUBE PULL 24FR ENFIT M00509021/M00509140
|
Facility
|
OP
|
$1,377.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563453
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$385.56 |
| Max. Negotiated Rate |
$5,508.00 |
| Rate for Payer: Aetna Commercial |
$1,239.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,184.22
|
| Rate for Payer: Aetna Managed Medicare |
$385.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$895.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$688.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$660.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$729.81
|
| Rate for Payer: Cash Price |
$413.10
|
| Rate for Payer: Cigna Commercial |
$1,266.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$770.57
|
| Rate for Payer: Health EOS Commercial |
$1,225.53
|
| Rate for Payer: HFN Commercial |
$1,266.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,032.75
|
| Rate for Payer: Multiplan Commercial |
$1,101.60
|
| Rate for Payer: NAPHCARE Commercial |
$826.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,266.84
|
| Rate for Payer: Quartz Beloit One Network |
$674.73
|
| Rate for Payer: Quartz Commercial |
$895.05
|
| Rate for Payer: Quartz Medicare Advantage |
$826.20
|
| Rate for Payer: The Alliance Commercial |
$5,508.00
|
| Rate for Payer: WEA Trust Commercial |
$757.35
|
| Rate for Payer: WPS Commercial |
$1,019.94
|
|
|
PEG TUBE PULL 24FR ENFIT M00509021/M00509140
|
Facility
|
IP
|
$1,377.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563453
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$674.73 |
| Max. Negotiated Rate |
$1,266.84 |
| Rate for Payer: Aetna Commercial |
$1,239.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,184.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$729.81
|
| Rate for Payer: Cash Price |
$413.10
|
| Rate for Payer: Cigna Commercial |
$1,266.84
|
| Rate for Payer: Health EOS Commercial |
$1,225.53
|
| Rate for Payer: HFN Commercial |
$1,266.84
|
| Rate for Payer: Multiplan Commercial |
$1,101.60
|
| Rate for Payer: NAPHCARE Commercial |
$826.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,266.84
|
| Rate for Payer: Quartz Beloit One Network |
$674.73
|
| Rate for Payer: Quartz Commercial |
$826.20
|
| Rate for Payer: WEA Trust Commercial |
$757.35
|
| Rate for Payer: WPS Commercial |
$1,019.94
|
|
|
PEG TUBE PUSH 24FR ENFIT M00509031/M00509150
|
Facility
|
OP
|
$1,377.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563452
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$385.56 |
| Max. Negotiated Rate |
$5,508.00 |
| Rate for Payer: Aetna Commercial |
$1,239.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,184.22
|
| Rate for Payer: Aetna Managed Medicare |
$385.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$895.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$688.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$660.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$729.81
|
| Rate for Payer: Cash Price |
$413.10
|
| Rate for Payer: Cigna Commercial |
$1,266.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$770.57
|
| Rate for Payer: Health EOS Commercial |
$1,225.53
|
| Rate for Payer: HFN Commercial |
$1,266.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,032.75
|
| Rate for Payer: Multiplan Commercial |
$1,101.60
|
| Rate for Payer: NAPHCARE Commercial |
$826.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,266.84
|
| Rate for Payer: Quartz Beloit One Network |
$674.73
|
| Rate for Payer: Quartz Commercial |
$895.05
|
| Rate for Payer: Quartz Medicare Advantage |
$826.20
|
| Rate for Payer: The Alliance Commercial |
$5,508.00
|
| Rate for Payer: WEA Trust Commercial |
$757.35
|
| Rate for Payer: WPS Commercial |
$1,019.94
|
|
|
PEG TUBE PUSH 24FR ENFIT M00509031/M00509150
|
Facility
|
IP
|
$1,377.00
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
5563452
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$674.73 |
| Max. Negotiated Rate |
$1,266.84 |
| Rate for Payer: Aetna Commercial |
$1,239.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,184.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$729.81
|
| Rate for Payer: Cash Price |
$413.10
|
| Rate for Payer: Cigna Commercial |
$1,266.84
|
| Rate for Payer: Health EOS Commercial |
$1,225.53
|
| Rate for Payer: HFN Commercial |
$1,266.84
|
| Rate for Payer: Multiplan Commercial |
$1,101.60
|
| Rate for Payer: NAPHCARE Commercial |
$826.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,266.84
|
| Rate for Payer: Quartz Beloit One Network |
$674.73
|
| Rate for Payer: Quartz Commercial |
$826.20
|
| Rate for Payer: WEA Trust Commercial |
$757.35
|
| Rate for Payer: WPS Commercial |
$1,019.94
|
|
|
PEG TUBE REPLACEMENT
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960310
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
PEG TUBE REPLACEMENT
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960310
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
PEG tube - Tube Type
|
Facility
|
IP
|
$1,324.00
|
|
| Hospital Charge Code |
3025915
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$648.76 |
| Max. Negotiated Rate |
$1,218.08 |
| Rate for Payer: Aetna Commercial |
$1,191.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,138.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$701.72
|
| Rate for Payer: Cash Price |
$397.20
|
| Rate for Payer: Cigna Commercial |
$1,218.08
|
| Rate for Payer: Health EOS Commercial |
$1,178.36
|
| Rate for Payer: HFN Commercial |
$1,218.08
|
| Rate for Payer: Multiplan Commercial |
$1,059.20
|
| Rate for Payer: NAPHCARE Commercial |
$794.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.08
|
| Rate for Payer: Quartz Beloit One Network |
$648.76
|
| Rate for Payer: Quartz Commercial |
$794.40
|
| Rate for Payer: WEA Trust Commercial |
$728.20
|
| Rate for Payer: WPS Commercial |
$980.69
|
|
|
PEG tube - Tube Type
|
Facility
|
OP
|
$1,324.00
|
|
| Hospital Charge Code |
3025915
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$370.72 |
| Max. Negotiated Rate |
$5,296.00 |
| Rate for Payer: Aetna Commercial |
$1,191.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,138.64
|
| Rate for Payer: Aetna Managed Medicare |
$370.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$860.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$662.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$635.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$701.72
|
| Rate for Payer: Cash Price |
$397.20
|
| Rate for Payer: Cigna Commercial |
$1,218.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$740.91
|
| Rate for Payer: Health EOS Commercial |
$1,178.36
|
| Rate for Payer: HFN Commercial |
$1,218.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.00
|
| Rate for Payer: Multiplan Commercial |
$1,059.20
|
| Rate for Payer: NAPHCARE Commercial |
$794.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.08
|
| Rate for Payer: Quartz Beloit One Network |
$648.76
|
| Rate for Payer: Quartz Commercial |
$860.60
|
| Rate for Payer: Quartz Medicare Advantage |
$794.40
|
| Rate for Payer: The Alliance Commercial |
$5,296.00
|
| Rate for Payer: WEA Trust Commercial |
$728.20
|
| Rate for Payer: WPS Commercial |
$980.69
|
|
|
PEG TUBE WITH BIOPSY
|
Facility
|
OP
|
$5,420.00
|
|
| Hospital Charge Code |
4075906
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,517.60 |
| Max. Negotiated Rate |
$21,680.00 |
| Rate for Payer: Aetna Commercial |
$4,878.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,661.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,517.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,523.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,710.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,601.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,872.60
|
| Rate for Payer: Cash Price |
$1,626.00
|
| Rate for Payer: Cigna Commercial |
$4,986.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,033.03
|
| Rate for Payer: Health EOS Commercial |
$4,823.80
|
| Rate for Payer: HFN Commercial |
$4,986.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,065.00
|
| Rate for Payer: Multiplan Commercial |
$4,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,252.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,986.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,655.80
|
| Rate for Payer: Quartz Commercial |
$3,523.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,252.00
|
| Rate for Payer: The Alliance Commercial |
$21,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,981.00
|
| Rate for Payer: WPS Commercial |
$4,014.59
|
|
|
PEG TUBE WITH BIOPSY
|
Facility
|
IP
|
$5,420.00
|
|
| Hospital Charge Code |
4075906
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,655.80 |
| Max. Negotiated Rate |
$4,986.40 |
| Rate for Payer: Aetna Commercial |
$4,878.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,661.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,872.60
|
| Rate for Payer: Cash Price |
$1,626.00
|
| Rate for Payer: Cigna Commercial |
$4,986.40
|
| Rate for Payer: Health EOS Commercial |
$4,823.80
|
| Rate for Payer: HFN Commercial |
$4,986.40
|
| Rate for Payer: Multiplan Commercial |
$4,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,252.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,986.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,655.80
|
| Rate for Payer: Quartz Commercial |
$3,252.00
|
| Rate for Payer: WEA Trust Commercial |
$2,981.00
|
| Rate for Payer: WPS Commercial |
$4,014.59
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC
|
Facility
|
IP
|
$58,108.00
|
|
|
Service Code
|
MSDRG 734
|
| Min. Negotiated Rate |
$20,902.04 |
| Max. Negotiated Rate |
$58,108.00 |
| Rate for Payer: Aetna Managed Medicare |
$20,902.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45,526.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,895.77
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,153.26
|
| Rate for Payer: Anthem Medicare Advantage |
$20,902.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20,902.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20,902.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20,902.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36,803.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20,902.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42,385.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20,902.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20,902.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20,902.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20,902.04
|
| Rate for Payer: NAPHCARE Commercial |
$31,353.06
|
| Rate for Payer: Quartz Medicare Advantage |
$20,902.04
|
| Rate for Payer: The Alliance Commercial |
$58,108.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20,902.04
|
| Rate for Payer: United Healthcare PPO |
$32,997.42
|
| Rate for Payer: Wellcare Medicare |
$20,902.04
|
|
